Policy: M2
Medicines Policy
Outlining medicines management
process in the trust
Version:
M2/V7
Ratified by:
Trust Management Team
Date ratified:
15th April 2015
Title of Author:
Chief Pharmacist
Title of responsible Director
Medical Director
Governance Committee
Clinical Effectiveness and Compliance
Date issued:
29th December 2015
Review date:
February 2018
Target audience:
Disclosure Status
All Staff Trustwide
B Can be disclosed to patients and the public
EIA / Sustainability
M2 - P3 Sustainable EIA form M2 2015
Development Screening
approved
Form Medicines
on 4th Feb
Policy
2015 by EIA review group.doc
Other Related Procedure or Documents:C31 - Controlled Drugs, S30p- Selfadministration of medication by inpatients procedure, C32p - Covert administration
of medicines procedure, C33p - Cold Chain Transport of Medicines And Handling
of Vaccines, 04p - Off label use of clozapine in know contra-indication procedure,
Trust Guidance: A14g - Approved off-label medicines, A13g - Approved unlicensed
medicines, Bg5 - BNF Borderline substances, R15g – Criteria for Re-use of
Patients own Drugs, P23g – Pharmaceutical Industry Sales Reps wanting to work
with WLMHT,
,
West London Mental Health NHS Trust
Policy M2 First date of issue: Sept 2005
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Equality & Diversity statement
The Trust strives to ensure its policies are accessible, appropriate and inclusive for all.
Therefore all relevant policies will be required to undergo an Equality Impact Assessment
and will only be approved once this process has been completed.
Sustainable Development Statement
The Trust aims to ensure its policies consider and minimise the sustainable development
impacts of its activities. All relevant policies are therefore required to undergo a
Sustainable Development Impact Assessment to ensure that the financial, environmental
and social implications have been considered. Policies will only be approved once this
process has been completed
West London Mental Health NHS Trust
Policy M2 First date of issue: Sept 2005
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M2: Medicines Policy
Version Control Sheet
Version Date
Title of Author
Status
Comment
M2/01
Sept 2004
Pharmacy
Department
New Policy issued
titled Medicines
Policy
New Policy replaced a previous
policy titled Policy & Practice
Relating to Medicines
M2/02
07.08.06
Pharmacy
Department
Revised Policy
issued
In Jan 2006 a revision made to
Appendix 1a - Clozapine
M2/03
09.01.09
Head of
Standard &
Compliance
Revised Policy
issued - Amended
for NHSLA
compliance
During the periods 31.10.08,
18.11.08 and 20.11.08 amendments
made and Appendix 3a and 3b
added
M2/04
23.10.09
Chief
Pharmacist
Revised Policy
issued
Review and updates for MCA and
MHA. Revised Policy approved by
CSSG on 23.10.09
M2/05
05.10.10
Chief
Pharmacist and
NHSLA
Consultant
Revised Policy
issued
31.03.10 - Amendments in line with
NHSLA requirements
05.08.10 - Additional items from
PRG added.
Revised policy under consultation
ending 03.09.10
Policy presented at 15th September
PRG – approved.
M2/06
September Chief
2012
Pharmacist
M2/07
Dec 14
April 2015
Additions in line with NPSA alerts
Removal of appendices
Controlled drugs separate policy
Changes TO s8.2.3, Approved at
Feb 2013 TMT.
Review
4 weeks trustwide consultation
ending 30th December 2014
Minor changes made to section
7.2.15, re-issued 29.04.15
Minor changes made to section 10.8
re-issued 29.12.15
West London Mental Health NHS Trust
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M2 - Medicines Policy
Ensuring the safe storage, prescribing, dispensing, handling and administration of
medication by personnel working for West London Mental Health NHS Trust;
outlining medicines management processes in the Trust
Contents
Page
1
Flowchart
5
2
Introduction (including purpose)
6
3
Scope
8
4
Definitions
8
5
Duties
9
6
Systems and Recording
10
7
The Prescription of Medication
10
8
The Pharmacist’s Role
22
9
The Supply of Medication
23
10
The Administration of Medication
25
11
The Storage, Transportation and Disposal of Medication
33
12
Medication brought in by Patient’s
34
13
Assessment of Nurses
35
14
Training
35
15
Monitoring
35
16
Glossary of Terms/Acronyms
35
17
NPSA Guidance & Alerts
36
18
References and Further Reading
36
Appendices
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1.
Flowchart
Prescribers
Check Allergy Status and document
on Prescription Chart and in RiO
Ensure additional
requirements are met when
prescribing:
Off-label
Unlicensed Medicines
Controlled Drugs
Clozapine
Lithium
Ensure medication is
regularly reviewed
for effectiveness and
adverse effect and
monitoring is carried
out in line with Trust
guidance
Every
opportunity
should be taken
to agree
Advance
Directives for
medicines
Carry out Medicines Reconciliation
(See M11 policy)
Discussion with patient regarding
treatment options should occur prior
to initiating medication and at regular
intervals to support shared decision
making. Provide written information.
Prescribe Medication in accordance with
policies, procedures and guidance
Consider allergies, contra-indications, cautions,
interactions, religious preferences, ethnic
metabolic differences and individual risks
Outpatient
Inpatient
Depot/LAI
FP10
Clozapine
Prescription
Pharmacy
Provide patients
with information
on medication
and treatment
options in written
and verbal form.
Pharmacist to screen prescription
to ensure appropriateness and
safety. Intervene as necessary
and supply as appropriate
Ensure additional requirements are met
e.g. clozapine monitoring
unlicensed medicines
lithium levels
Audit use of Medicines
Ensure Safe and Secure
Handling of medicines at a
Department level
Nursing
Administer Medication in line with
Trust policy, procedures and
Guidance and NMC guidance
Monitor effectiveness of
medication
Monitor for adverse
effects of medication
Feedback concerns
regarding medication to
MDT
Ensure Safe and Secure
Handling of medicines at a
ward/team level
Use of medicines should be in line with the principles of medicines optimisation:
1. Aim to understand the patient’s experience
2. Evidence based choice of medicines
3. Ensure medicines use is as safe as possible
4. Make medicines optimisation part of routine practice
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2.
Introduction
2.1
This policy is designed to assist medical, pharmacy and nursing staff to ensure a
high standard of prescribing practice and medicines management and optimisation.
It must be used in conjunction with Trust prescribing guidance (found on the
Exchange in Medical and Patient Care - Medicines Management and Optimisation
webpage) and any local hospital formularies and guidelines approved for use within
the Trust. Additional advice can also be sought from the trust pharmacy team on
non-psychiatric medicines.
2.2
All clinical staff with responsibility for medicines management, medicines
optimisation and prescribing must adhere to this Trust Policy.
2.3
Use of medicines should be in line with the four principles of medicines optimisation:

Aim to understand the patient’s experience

Evidence based choice of medicines

Ensure medicines use is as safe as possible

Make medicines optimisation part of routine practice
2.4
A member of staff must not accept a task beyond their capability or training. All
individuals have a responsibility to ensure that they are competent to carry out their
medicines management responsibilities and that they are prepared to be
accountable for their actions. Professional accountability remains with each
registrant to ensure that they adhere to practice guidance from their professional
body with respect to medicines management.
2.5
Where a medication incident, error or “near miss” occurs, the staff involved must
report the incident immediately in accordance with the Incident Reporting Policy.
This should include the recognition of a potential risk that could cause an
error/medication incident - e.g. look alike meds, sound alike meds, unclear
prescribing. Potential risks should also be discussed with the appropriate doctor,
pharmacist and medicines management technician to ensure all actions are taken
to prevent the risk identified. The Trust, which operates in a Fair Blame culture,
recognises that clinical errors can occur and in such an instance, it is essential that
the matter be reported promptly and fully.
2.4.1 The patient involved must be informed by the clinical team of the error that has
occurred and counselled on the likely risk and outcomes of the incident. This
discussion must be recorded in the patient’s clinical record. They should be
reassured that the error is being investigated to avoid it happening again and that
their care is a priority.
2.4.2 Quarterly summaries of CSU reports of medication errors will be presented to the
trust Medicines Management Group to encourage shared learning by all areas, to
identify common themes and, where necessary, develop action plans in response to
these.
2.5
Regular audits of compliance of practice with this Policy will be undertaken to
ensure best practice and patient safety, and to identify areas for education and
training initiatives. Medication incident reports and investigations will be scrutinised
against these standards The Deputy Director of Nursing in each clinical service unit
(CSU) will be responsible to ensure that action plans and practice changes are
implemented and monitored. Progress reports are to be fed back in appropriate
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Trust/ Local forums. Quarterly summaries of CSU medication audits and action
plans will be presented to the trust Medicines Management Group to encourage
shared learning by all areas.
2.6
The monitoring of side-effects of medication prescribed and administered by
clinicians is the responsibility of the Multidisciplinary team. It must be carried out in
line with the Trust’s BNF Bookmark (available from pharmacy), the Trust’s
Standards on side effect monitoring and where appropriate or for specific medicines
according to the manufacturer’s advice and more frequently if the patient has
additional underlying physical health risks.
2.7
High secure services should be mindful of the High Secure Psychiatric services
directions which relate to the control of prescribed medicines at Broadmoor
Hospital.
2.8
All staff must be aware that any instances where there is any suspicion that there
has been unauthorised administration or supply of medicines to anyone other than a
Trust patient, e.g. a member of Trust staff or other third party, that this must be
referred to either the Police or the Trust’s Local Counter Fraud Specialists for
investigation.
2.9
Where staff have any suspicion that medicines are being taken or used by either
another member of staff or a third party they have a duty to report this to either their
line manager or in confidence to the Trusts Local Counter Fraud Specialists (LCFS).
Further details of the Trust’s Counter Fraud Policy, and means of reporting your
suspicions, is available on the Exchange or Fraud & Corruption Reporting Line 0800
028 40 60 (office hours).
2.10 The Chief Pharmacist, Director of Nursing or Medical Director may instigate special
recording and storage procedures in the event of suspicion of misuse of any
medicine, controlled or otherwise.
Relevant Trust Policies:
 Consent to Examination or Treatment C7
 Controlled Drugs Policy and Standard Operating Procedures C31
 Disciplinary Procedure D4
 Handling Concerns About A Doctors’ Performance (including guidance
on disciplinary procedures) D4A
 Death of a Patient D6
 Counter Fraud Policy F2
 Health and Safety H3
 Infection Prevention and Control Policy and Guidelines ICP1
 Waste Policy ICP10
 Incident Reporting and Management I8
 Medicines Reconciliation M11
 Mental Capacity Policy M9
 Missing Persons and Patients Absent Without Leave P1
 Management of Illicit Substances P14
 Non-Medical Prescribing N6
 Risk Management R1
 Rapid Tranquilisation R10
 Seclusion S2
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


Violence Reduction and Management V2
Whistleblowing W1
Local Procedures specific to individual units
Specific teams e.g. Crisis Resolution, The Cassel have local procedures which
complement this Policy and must be used by all members of such teams. There are
also a number of Trust procedures and guidelines relating to medication.
3.
Scope
3.1
The Department of Health requires that NHS Trusts establish, document and
maintain an effective system to ensure that medicines are handled in a safe and
secure manner. The policy covers medicines and related non-medicines both of
which are defined within the Glossary.
3.2
This policy document outlines the mandatory legal and ethical aspects
involved in the processes surrounding medication and will cover the following
areas.

Supply of Medication

Storage of Medication

Disposal of Medication

Prescribing of Medication

Administration of Medication
3.3
This policy applies to all employees of West London Mental Health Trust and covers
all aspects of medication.
3.4
This policy covers those members of staff who are identified as having the required
legal authority to engage in the processes listed.
4.
Definitions
The following definitions of these terms are to be applied throughout the Medicines
Policy.
4.5
Prescribing
To authorise by means of a prescription the supply of any medication. May be
carried out by a doctor or a suitably trained non-medical prescriber.
4.6
Dispensing
To prepare medication against a valid prescription in a manner to ensure the safe
and effective use of that medication in the environment where it will be
administered. Consideration is given to suitability of medicine with respect to
indication, dose, adverse reactions, and precautions. Records must be kept.
Dispensing may only be carried out by pharmacy staff.
4.7
Administration
A nursing intervention defined as preparing, giving, and evaluating the effectiveness
and adverse effects of prescribed medication.
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4.8
Issuing Medication
The delivery or handing over of medicines in person to a patient or carer for the
purpose of self administration by the patient. The medication must have been
dispensed by pharmacy and clearly labelled with instructions for administration.
5.
Duties
5.1
Chief Executive
The Chief Executive has the overall statutory responsibility for the safe and secure
handling of medicines within the Trust with ultimate responsibility for the
implementation and monitoring of policies in use in the Trust. This responsibility
may be delegated to an appropriate colleague.
5.2
Medical Director
The Medical Director is the Executive Director responsible for Pharmacy and
Medicines Management and has Trust Board responsibility for all aspects of
Medicines Management. They are also responsible for ensuring all medical staff
are trained to carry out the tasks required of them in the prescribing and
management of medicines.
The Medical Director is supported by the Trust’s Medicines Management
Committee.
5.3
Chief Pharmacist
The Chief Pharmacist is Chair of the Medicines Management Group and has
responsibility for co-ordinating the activities of the Medicines Management Group to
ensure that good practice relating to medicines, as described in this policy,
becomes embedded in to everyday working practice across the Trust. The Chair
will raise any medicines management issues at the Clinical Effectiveness and
Compliance Group.
The Chief Pharmacist is also responsible for ensuring all pharmacy staff are trained
to carry out the tasks required of them in the management of medicines.
5.4
Medicines Safety Officer (MSO)
All NHS Trusts are required to have a MSO. The role of the MSO is to improve
medication error incident reporting and learning . This involves improving quality of
and increasing reporting, improved communication between local and national
networks as well as implementing patient safety alerts from NHS England, sharing
lessons learned from local and national medication incidents and being a member
of the national medication safety network.
5.5
Prescribing Staff
Medical staff and non-medical prescribers are responsible for prescribing medicines
for patients. It is their responsibility to comply with legislation, the Trust Medicines
Policy and associate policies, procedures and guidelines. Prescribing staff should
also prescribe within the Trusts medication formulary guidelines and adhere to the
principles of medicines optimisation.
5.6
Pharmacy Staff
Responsible for providing information and advice to Trust personnel on all aspects
of medicines management within the Trust, assisting where appropriate in
formulating local procedures at ward/departmental / level, ensuring that the laws
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relating to the safe and secure handling and storage of medicines are complied
with.
5.7
Ward Staff
The Practitioner in Charge of the ward is responsible for all aspects of management
of medicines within their ward or department at all times and are Responsible for
the operational implementation of the Medicines Policy, including ensuring staff
within their ward / department attends appropriate training.
Ward staff are responsible for carrying out duties related to medicines management
in accordance with this and other medicines related policies.
5.8
Committee’s etc.
The Medicines Management Group is responsible for the development, updating
and monitoring of this policy.
The Drugs and Therapeutics Committee is responsible for developing guidance on
prescribing for Trust clinicians.
5.9
All staff
Are responsible for undertaking appropriate medicines management training and
following guidance set out in this Policy and any other medicines related policy,
procedure or guidance.
6.
Systems and recording
Prescribing and
administration
record
Pharmacy
Screening
Rational for
prescribing,
including initiating,
dose changes and
stopping treatment
Efficacy review
Refusal of
medicines
PRN reason for
use
Medication
Incidents
Where recorded
Prescription
Charts
When recorded
At point of
prescribing and
administration
Pharmacy check
Recorded by who?
Doctors
NMP
Nurses
Pharmacists
Patient electronic
Record
Changes to
prescription
Regular reviews
Patient refusing
medication
Following
administration of
PRN medication
Doctors
NMP
Nurses
Pharmacists
IR1
At point of
recognition of
incident
Identifier of
incident
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7.
The prescription of medication
7.1
Only staff suitably qualified and employed by WLMHT, including those on an
Honorary Contract may prescribe on Trust stationery.
7.1.1 All medication prescribed will follow Trust prescribing guidelines and
recommendations from the WLMHT Drugs and Therapeutics Committee (DTC)
available on the Medicines Management and Optimisation page of the Exchange,
and prescribing will be compatible with General Medical Council Code of Practice
for doctors or other professional bodies for non-medical prescribers.
7.1.2 A discussion with each patient regarding treatment options should occur prior to
initiating medication and at regular intervals to support shared decision making.
Written information should be provided.
7.1.3 Prior to initiating a prescription allergy status must be assessed and documented in
in the patient’s electronic case record by the prescriber. This should be entered in
the allergy section on RiO which can be accessed from the case record header bar
by clicking on the
button. There are three tick box options; unknown, no
allergies/adverse reactions or allergies/adverse reactions. Unknown is the default
position on RiO (this should only be used when information cannot be found and
should be updated as soon as information becomes available). If there are ‘No
Known Drug Allergys’ (NKDA) or no adverse reactions tick the no allergies/adverse
reaction box. If allergies/adverse reactions are present these need to be added by
clicking add at the bottom of the page. Add the substance in question, specify
reaction type (allergy or adverse reaction) and add the reaction type e.g. rash.
Complete the rest of the fields and save.
If there are no allergies/adverse reaction the button will be green
.
If any allergies/adverse reactions have been entered the button will change colour
to red
. Where a Trust prescription chart is in use the allergy status must also be
written clearly in the ‘Drug Allergies, Sensitivities and Cautions Specify Medicine
and reason’ red box. Sensitivities must be re-checked with the patient (where
possible) if the patient has been re-admitted or is being seen as an out-patient.
7.1.4 Attention must be paid to information available on metabolic differences in specific
races e.g. some ethnic groups may metabolise medication at different rates and this
should be taken into consideration when prescribing.
7.1.5 Consideration should be made in line with peoples’ religious preferences and
personal beliefs when choosing the most appropriate formulation. Some products
may contain pork or beef derivatives, and liquids may contain alcohol.
7.1.6 Attention must also be paid to the administration of medicines during fasting e.g.
Ramadan.
7.1.7 On admission of a patient to inpatient or outpatient services, the admitting doctor
must make every attempt to confirm the accuracy of prescribing by assessing the
patient’s previous medication history before prescribing for them (Ref M11
Medicines Reconciliation Policy) and obtain baseline measures of physical health
before initiating treatment.
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7.1.8 Medication reconciliation should also occur on patient transfer between different
clinical areas and on discharge from hospital to ensure the accuracy of the
information.
7.1.9 Where a patient has an advanced directive/decision regarding medication this
should be considered when selecting the medication. If an advance decision is not
followed because the service user is detained under the Mental Health Act 1983, a
full explanation must be given to the service user explaining why it was thought in
their best interests not to follow the advance decision. (M9 – Mental Capacity
Policy)
7.1.10 When prescribing medicines a risk assessment should be carried out. This should
include risk of adverse effects, overdose and abuse potential of medicines.
Limited supplies and medicines with least risk in overdose should be prescribed for
patients at risk of deliberate self-harm.
Consider prescribing medications in liquid form (where available) to avoid hoarding
and selling.
7.1.11 The Approved Clinician (AC) or doctor with prescribing responsibility will
periodically review the patient’s Consent to Treatment and must carry out the
review:
a) When there is a change of the patient’s consultant psychiatrist: The Code of
Practice states ‘a new Form T2, T4, T5 or CTTO must be issued when there is
a permanent change of Consultant psychiatrist’ but a T3 can remain unless the
patient now has capacity to consent.
b) When the patient’s detention is reviewed or annually, whichever is earlier. The
AC must always record their assessment of capacity when reviewing consent to
treatment, as required in the Mental Health Act (MHA) Code of Practice. The
assessment of capacity to consent to treatment must be clearly documented by
the AC following each review or annually, whichever is soonest.
7.1.12 Prescriptions may only be written for registered patients of the Trust, and only using
approved Trust stationery. No staff may use medication or prescription forms for
themselves, relatives or colleagues.
7.1.13 Prescribers must familiarise themselves with the licensed indications of medication
before prescribing. This information is available in the latest edition of the BNF
which can be accessed on line at medicinescomplete.com, via the link on the
Managing Medicines page of the Exchange, or at the ‘product characteristics’ site,
www.medicines.org.uk




Off-label use of licensed medication - - should be considered only when
licensed alternatives are not suitable.
The use of unlicensed medication –– should be considered only when licensed
alternatives are not suitable and requires specific documentation to be
completed before it can be ordered by the Trust pharmacy.
Clinical trial and subsequent ‘open label’ medicine must be prescribed in line
with agreed protocol-specific agreements, following Chief Pharmacist and
research and development approval -.
In all such cases, obtaining informed consent is essential.
7.1.14 Non-medical prescribing (NMP) is defined in the NMP Strategy and Policy. New
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prescribing protocols must be agreed by the Non-Medical Prescribing Group, a subgroup of Medicines Management, and will only be developed where clear benefit to
patients is identified by the Trust.
7.1.15 Herbal medicines and other non-medicinal products may not be prescribed for use
by Trust patients. Clinicians must also advise caution over self-administration of
such products in conjunction with prescribed medication as the safety of such
practice cannot be assured. Advice on supplements and vitamins should be sought
from pharmacy.
7.1.16 All clinical trials must have prior approval of a Research Ethics Committee, the
Medicines and Healthcare products Regulatory Agency (MHRA) and be approved
by the Trust Research and Development Steering Group. Clinicians intending to be
involved in any research that involves medication must discuss the protocol with the
Chief Pharmacist at the earliest possible opportunity to ensure sufficient time to
facilitate dispensing.
7.1.17 If a service user has been diagnosed with a condition that requires the use of an
oral nutritional supplement or an enteral feed, a Registered Dietitian can write these
on the patients prescription chart as per trust guidance on BNF listed borderline
substances (link).
7.1.18 All prescribers must adhere to the Trust guidance on working with Industry as
outlined in the Business conduct policy (link) and Trust Procedure: Pharmaceutical
Industry Representatives wishing to work with WLMHT.
7.2
Writing a Prescription
7.2.1 It is the responsibility of every doctor or non-medical prescriber prescribing
medicines to ensure that (s)he has up-to-date information (e.g. eBNF via Exchange
Managing Medicines page) on dosage and licensed indication, and to consider
carefully whether any of the prescribed medicines will, or may, interact adversely
with each other.
To ensure accuracy of prescriptions on admissions the Trust M11 Medicines
Reconciliation Policy requires that the team the patient is admitted under ensures
all available sources of medication history information are checked before a
prescription is written. A record of sources checked must be made in the patient’s
clinical record and annotated on the prescription chart within 24 hours of admission
to the service
7.2.2 Attention must always be paid to the Mental Health Act and Mental Capacity Act
with respect to Consent to Treatment legislation requirements
7.2.3 The use of Section 62 must be considered for emergency treatment which is not
covered by current consent forms for detained patients
7.2.4 All sections of the WLMHT prescription chart must be completed in full, and state
clearly the patient's name, NHS number (or RiO number or address if using outpatient forms), and date of birth. This information can be either hand -written,
printed or by using a patient’s clinical record label. All other demographic
information necessary for the safe prescription and monitoring of medicines must be
completed e.g. weight, height, swallowing difficulties
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7.2.4.1 Prescriptions must be written legibly using the recommended International Nonproprietary name (rINN), except where there is inter-brand variability, in which
case the proprietary name should also be used.
7.2.4.2 Capital letters must be used for prescriptions and abbreviations must not be used.
Prescriptions must be written in black or blue ink.
7.2.4.3 The exact dose, formulation, frequency and the route must be clearly stated on
the WLMHT prescription form in full, and the sections stating ‘T2, T3, S62 or NA’
and ‘within BNF max Y/N’ completed Where depot or long acting injections are
prescribed the route of administration must be specified e.g. gluteal, deltoid.
7.2.4.4 NB where products are altered e.g. tablets are crushed prior to administration this
may constitute Off-Label Use
7.2.4.5 Ranges of doses must be clearly explained and only used when considered
essential.
7.2.4.6 All prescription items must be signed and dated by the prescriber, who must also
PRINT their name. Administration record forms must have a start date for each
treatment and a review or stop date entered if appropriate, in the relevant section
of the prescription chart.
7.2.4.7 The list of ‘homely remedies/discretionary medicines’ on the back page must be
reviewed for appropriateness to be given for up to 48 hours without consulting a
doctor, with deletions made as necessary, before being authorised with a
signature and date in the boxes below the list.
7.2.4.8 The number of charts in use for a patient at any one time must be clearly specified
on each prescription chart.
7.2.4.9 Clear documentation regarding current medication prescribed must be made in the
patients care plan under a problem heading of "Treatment" with an intervention type
"physical" and a subheading of “Medication". This should include information
regarding indication, side effect monitoring and adherence issues.
7.2.4.10 Advance directives and statements regarding medication should be included in
the care plan.
7.2.5 Choices and changes of medication must be discussed with the patient and
potential benefits and adverse effects clearly explained - see section 5.5. This will
be documented in the patient’s clinical record, as will reasons for any exceptions to
this requirement. The prescriber should regularly monitor patients for adverse
effects of medication and take appropriate action which should include reassuring
the patient and may involve increased physical observations, blood tests, dose
adjustments, stopping or switching medication. All adverse effects must be clearly
documented in the patients care record and sensitivities to medication should be
documented in the appropriate box on the front page of the inpatient prescription
chart.
7.2.6 Changes to the dose, frequency or route of a medicine must be completely
rewritten on the prescription chart and be made with reference to the current
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consent status. When stopping a prescription enter a stop date, cross through
both the prescription box and any unused administration boxes and write the
reason for stopping, e.g.' dose reduced due to high levels'.
7.2.7 Quantities of 1 gram or more must be written in grams, for example: 1g. Quantities
of less than 1 gram must be written in milligrams or micrograms e.g. 500 milligrams
or 5 micrograms. When prescribing the quantity in UNITS this must be written in
full, abbreviations should never be used. Prescribers should avoid the use of a
capital '1' which may look like a 2 or a 7 when written. Do not use a comma instead
of a decimal point (e.g. use 2.5 rather than 2,5).
7.2.8 ‘Once Only’ medication must be prescribed within the applicable section on the
front of the chart and rewritten if subsequent doses are required; the word 'repeat'
must not be used.
7.2.9 Variable dose regimes e.g. clozapine titration or chlordiazepoxide withdrawal must
be prescribed on the variable dose section with an entry in the regular section of
the chart with the note ‘see front of chart for variable dose’.
7.2.10 Any physical health medication that needs to be prescribed with loading doses
should be prescribed on the variable dose schedule of the prescription chart.
Advice on loading doses for physical health medications must be sought from the
local acute trust. There is no evidence to suggest greater efficacy or quicker
response with loading doses of oral psychotropics. Advice on loading doses of long
acting injectable psychotropic medication is available from pharmacy. The loading
dose and subsequent maintenance dose regimens must be clearly documented in
the patient’s record.
7.2.11 For in-patients, all regular oral medication must be prescribed on the regular
section of the chart, long acting injections must be prescribed on the long acting
injection section and any medication likely to be required in addition to the regular
prescription must be prescribed on the ‘prn’ (when required) section of the
individual’s prescription chart, or authorised for nurses to administer under
‘discretionary medicines’ (also known as homely remedies) on the chart. The
indication for 'as required’ medication must be clearly stated e.g. codeine
phosphate “for diarrhoea”, indicating that this medication is not for analgesic
purposes. The hourly interval, monitoring requirements, ‘total dose in 24 hours‘,
must be clearly stated. Care must be taken to avoid the possible duplication or
interaction of medicines prescribed stat, regularly, prn, and discretionary.
7.2.12 It is recognised that the transcription of prescription charts can lead to errors and
loss of information. It is therefore imperative to ensure accuracy of rewritten
prescription charts that the prescriber ensures all relevant information is
transcribed from the original chart as well as checking the accuracy of the
information transcribed.
7.2.13 Inpatients who are transferred to another ward within the Trust must be sent with
their current prescription chart. To prevent transcription errors this chart should be
used following the transfer.
7.2.14 Inpatients who are to be transferred to a different inpatient organisation must have
a discharge prescription completed.
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7.2.15 Short Leave and discharge medication must be prescribed on the ‘medicines for
short term leave’ or ‘Discharge Prescription/7 day follow up’ (available as an
editable letter in RIO) respectively.
On discharge a 28- or 30- day pack of each medicine is usually given.
Consideration must be given to the Suicide Prevention Strategy and other Trust
policies – if a smaller quantity is required the prescription must be endorsed
‘EXACT QUANTITY ONLY’ Changes in medication made to the inpatient
prescription chart must be transcribed onto the discharge/leave prescription and
vice versa.
A copy of the discharge letter must be sent to the patient’s GP as close as
possible to the discharge date to ensure continuity of medication records on
discharge.
7.2.16 If discharge or leave medication is required 'out of hours', an FP10 should be used
from the out of hours cupboard which can be accesses via the unit co-ordinator.
7.2.17 Prescriptions of controlled drugs must follow the controlled drugs policy and
standard operating procedures.
7.2.18 It is not acceptable to give a telephone order to administer a medicine which has
not previously been given to the individual being assessed.
In exceptional circumstances, when the potential benefit to the patient outweighs
the risk of no timely intervention as the prescriber is unable to issue a new
prescription, and where the medication has been previously prescribed, but where
changes to the dose or prescription are considered necessary, the use of
information technology (such as fax or e-mail) is the preferred method of ‘verbal
order’ for a single dose. This should be followed up by a new prescription signed by
the person giving the order, confirming the dose within a given time period; the
NMC suggests a maximum of 24 hours. In any event, the dose must have been
authorised before the next dose is administered.
7.2.19 Any recommendations regarding prescriptions, as highlighted by pharmacists on
prescription charts (in green pen) must be considered by the prescribing doctor as
soon as possible and discussed further with the pharmacist if necessary.
7.2.20 Reporting should occur for all adverse reactions for medicines which are endorsed
with a black triangle in the BNF, and all suspected reactions to established drugs
that are serious, medically significant, or result in harm. These should be reported
using the MHRA Yellow Card Reporting system online at
http://www.mhra.gov.uk/Safetyinformation/Reportingsafetyproblems/Reportingsusp
ectedadversedrugreactions/index.htm. Forms are also available in the back of the
BNF. A Trust incident form (IR1) should also be completed.
7.3
‘High Dose’ Antipsychotic Medication See also section 5.4.3 (off-label
prescribing)
NOTE: The Royal College of Psychiatrists’ 2006 ‘Consensus Statement on
high-dose antipsychotics’ states: on the basis of current evidence, high-dose
prescribing, either with a single agent or combined antipsychotics, should
rarely be used and then only for a time-limited trial in treatment-resistant
schizophrenia after all evidence-based approaches have been shown to be
unsuccessful or inappropriate.
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7.3.1 ‘High dose’ is defined as ‘a total daily dose of a single antipsychotic which exceeds
the upper limit stated in the Summary of Product Characteristics (SPC) or BNF’ and
‘a total daily dose of two or more antipsychotics which exceeds the SPC or BNF
maximum using the percentage method’.
The percentage method requires the conversion of the dose of each medication into
a percentage of its BNF maximum dose, and adding the percentages together – a
cumulative dose of more than 100% is a high dose.
7.3.2
Where any medication is prescribed in excess of BNF recommended doses, this
must be discussed with and recorded in the patient’s clinical record, with an
explanation and a clear care plan which will be reviewed by the multidisciplinary
team at regular intervals. The patient should be informed that they are receiving
‘high dose’ and this too should be recorded and the section on the in-patient
prescription form stating ‘within BNF max Y/N’ completed.
7.3.2.1 Monitoring requirements for pulse, temperature and blood pressure will be outlined
clearly in the care plan for the individual patient. An electrocardiogram (ECG),
taken before treatment is started, must be available for comparison at regular
intervals to observe any changes during treatment.
7.3.3. All patients who are on high dose antipsychotics must be encouraged to have a
good fluid intake of at least two litres daily, which is recorded in their care plan and
monitored on a fluid chart.
7.3.4 Junior doctors must consult with their respective consultant or consultant on- call
prior to prescribing any medicines above the BNF recommended maximum doses.
7.3.5 When doses in excess of BNF maximum are prescribed, the consent forms must
also reflect the prescribed doses.
7.4
Off-Label and unlicensed prescribing
7.4.1
The Medicines Act 1968 requires the marketing, manufacture, dispensing, sale,
supply or importation of medicine to be regulated by a Marketing Authorisation
(MA) (previously Product Licence) issued by the Medicines and Healthcare
Products Regulatory Agency (MHRA). A medicine’s MA permits the
manufacturing company to market the medicine for a specified clinical indication
and states the conditions that limit its use.
7.4.2
There are two main ways in which medicines may be used in clinical practice that
fall outside the strict provisions specified by marketing authorisation. Firstly, a
medicine that does have an MA might be prescribed outside the conditions of the
MA. This is termed off-label prescribing. Secondly, a medicine may be used that
has no MA in the UK. This is unlicensed prescribing.
Further details of off-label and unlicensed prescribing are given below
7.4.3
Off-label prescribing
7.4.3.1 ‘Off-label’ prescribing refers to the use of a licensed medicine outside of the
specifications of the products marketing authorisation. This includes using the
medication at doses above the recommended range, for a clinical indication or in
an age group outside of the marketing authorisation, or delivering the medicine as
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a different formulation from that specified (e.g. crushing tablets).
7.4.3.2 Certain ‘off label’ uses of medicines are well established in clinical practice and
widely supported in the medical literature. In instances where the medicine has
been available for many years, it may not be commercially viable to apply to the
MHRA for an extension to the Marketing Authorisation. Similarly, since clinical
trials during the development of the drug are often undertaken in adults, it may not
be viable to replicate the trials in children or the elderly in order to extend the age
range of the Marketing Authorisation.
7.4.3.3 If a medicine is being prescribed outside the conditions of the license/ MA, the
Patient Information Leaflet (PIL) included in the medicine packaging is not
applicable to the current use. Indeed, there may be contradictions, for
example, the PIL saying that the medicine is not authorised for children,
when in fact you are prescribing it to a child. The prescriber is therefore
responsible for providing sufficient information to enable the person
consenting to the treatment to make an informed decision and
documenting that they have done so. Some leaflets for this purpose are
available on the Exchange.
7.4.3.4 The product manufacturer is only likely to be found liable, if harm results from a
defect in the product. The manufacturer carries no legal liability for a medicine
prescribed outside the terms of the licence (specifying medical indication,
preparation of drug and age of patient). This places greater responsibility on
individual prescribers and the Trust to defend their use of the medicine in relation
to the evidence for its effectiveness and likelihood of producing adverse effects.
The ultimate responsibility for prescribing lies with the doctor who signs the
prescription and is professionally accountable for his/her judgement.
7.4.3.5 Guidelines for Off-label Prescribing
7.4.3.6 When writing a prescription, it is the clinician’s responsibility to be aware of
whether they are prescribing within the terms of the MA or off-label. Prescribers
can refer to:
 The BNF.
 The pharmacy.
 The list of recognised off-label indications supported by the DTC. (Link)
7.4.3.7 Where there is a licensed option for treatment, this should be the preferred option
unless the prescriber is able to justify their decision to reject this option and select
an off-label option in accordance with the clinical evidence base.
7.4.3.8 When prescribing for an ‘off-label’ indication, the prescribing doctor must take
responsibility for ensuring that there is a written justification of the decision to
prescribe off-label in the clinical notes. Except for the indications in the recognised
off-label indications list, this should include reference to published and other
evidence supporting the use of the chosen medication for the particular indication
concerned.
7.4.3.9 The use of clozapine on an off-label basis must follow the Trust guidance. (Link)
7.4.3.10

Communication with the person consenting to treatment must include:
Informing that the medicine is being used outside the terms of the licence.
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



Explaining why this medication has been chosen in preference to others.
Providing sufficient information about the benefits and potential adverse
effects of using the medicine for this particular indication that the person
giving consent can make an informed decision.
Agreeing a plan to monitor response to treatment and detect adverse events.
Explaining any discrepancies between the above information as it applies to
your patient and the information supplied by the Patient Information Leaflet,
packaged with the medication.
7.4.3.11 A record that these points have been communicated should be made in the
clinical records.
7.4.3.12
When the patient is being treated under the Mental Health Act, the assessment
and recording of informed consent becomes even more critical where
medication is used off-label. As with other off-label prescribing, the key principle
must be that the choice of medication over others (including medications
licensed for the indication concerned) is justified on the basis of available
research evidence as being in the individual patient’s best interests. The
prescribing consultant will be expected to document in greater detail than usual
either the patient's consent or the plan of treatment to be approved by the
Second Opinion Approved Doctor (SOAD), specifying either that the patient
understands that this is off-label prescribing, or that the SOAD understands that
this is the proposal.
7.4.3.13 Where available, user friendly information leaflets should be offered to patients
and carers. Note that such information leaflets must supplement, rather than
substitute for the manufacturer’s Patient Information Leaflet, which will be
supplied with the medications when dispensed.
7.4.4
Clinicians responsibility when prescribing ‘off-label’
7.4.4.1
Where medications are prescribed for off-label indications, clinicians must
expect to accept liability for their prescription. How liability is shared between
the prescriber and the Trust cannot be fully specified beforehand in such
instances. Prescribers who have concerns about individual instances of offlabel prescribing are invited to discuss these with the Chief Pharmacist.
7.4.4.2
The Drugs and Therapeutics committee have approved a list of medicines
where it is considered that there is a sufficient body of evidence to support the
off-label use of the specified medicine in the indication described (See Trust
Guidance: Approved Off-label Medicines).
7.4.4.3
The prescriber has the responsibility for collecting and collating the published
and other evidence concerning the particular off-label indication proposed.
7.4.4.4
Prescribers who wish for the consideration of an off-label indication of a licensed
medication to be included in the off-label list should make a request to the DTC
for review (See Trust Guidance: Approved Off-label Medicines).
7.4.4.5
The Prescribers who are Trust staff should recognise that general practitioners
are not covered by Trust liability as described above, and may decline to
prescribe off-label. Where general practitioners are asked to prescribe off-label,
Trust prescribers should ensure that the general practitioners are given full
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details of the indications and monitoring requirements, including notification of
informed consent having been obtained.
7.4.5
Unlicensed prescribing
Unlicensed prescribing refers to the use of a medicinal product without a United
Kingdom Marketing Authority.
Examples include:
i. Medicines manufactured under license in other countries.
ii. Medicines awaiting a UK MA.
iii. Medicine manufactured under a ‘Specials’ License.
7.4.6.
Implications of using unlicensed medications
7.4.6.1
By definition, the absence of an MA means the quality of the medicine cannot be
assumed and fitness for its intended use may need to be established.
Furthermore, the manufacturer cannot be held liable for any adverse outcomes,
and may not claim any medicinal properties. Hence more responsibility must
rest with the prescriber and with the pharmacy.
7.4.6.2
The Act requires that an unlicensed product can only be used if there is no
licensed alternative available. If there is a licensed alternative available that is
considered to be pharmaceutically suitable, then that medicine has to be used.
7.4.6.3
The procedures below are all necessary to fulfil the legal obligations of those
involved under the Medicines Act.
7.4.7
Consultants’ Responsibilities when prescribing unlicensed medicinal products
7.4.7.1
The consultant wishing to prescribe the unlicensed product must submit an
unlicensed product request (See Trust Guidance: Approved Unlicensed
Medicines) to the DTC with a prescribing protocol. The consultant will be
responsible for providing evidence to the DTC supporting the proposed use of
the medication from peer-reviewed reports by at least two groups of researchers
independent of each other. Collecting and collating the materials for the
submission is the responsibility of the consultant.
7.4.7.2
Before the medication is dispensed, the consultant will be required to complete a
further form (See Trust Guidance: Approved Unlicensed Medicines), to be
returned to the pharmacy being asked to dispense the medication, indicating
that the consultant understands his/her responsibilities, and accepts them.
7.4.7.3
7.4.7.4
The consultant is responsible for the safety and efficacy of the medicinal
product and defining the process for its administration. Necessary
documentation confirming an understanding of the unlicensed status and
record keeping requirements must be completed by the consultant for any
doctor in their team.
The prescriber must inform the patient (or carer where appropriate) of the fact
that the product is unlicensed and explain that its effects will be less well
understood than those of a licensed product. Where possible, written consent
must be obtained.
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7.4.7.5
When the patient is being treated under the Mental Health Act, the assessment
and recording of informed consent becomes even more critical where an
unlicensed medication is used. The key principle must be that the choice of a
particular medication is justified on the basis of available research evidence as
being in the individual patient’s best interests. The prescribing consultant will be
expected to document in greater detail than usual either the patient's consent or
the plan of treatment to be approved by the Second Opinion Approved Doctor
(SOAD), specifying either that the patient understands that the medication to be
prescribed is unlicensed, or that the SOAD understands that this is the proposal.
7.4.7.6
It is expected that prescription of unlicensed medications will be initiated by a
consultant. Even where some of the tasks listed are devolved to other medical
members of the team, the responsibility for ensuring that the policy is strictly
adhered to remains with the consultant.
7.4.7.7
The consultant must report immediately any adverse reactions to the Chief
Pharmacist, and these reports will be reviewed by the DTC.
7.4.7.8
GPs must never be asked to prescribe unlicensed medicines. Similarly,
arrangements for dispensing must always be with the local Trust pharmacy,
rather than any community pharmacy.
7.4.8
Drugs and Therapeutics Committee (DTC) Responsibilities
7.4.8.1
The DTC will need to decide whether the potential benefits of prescribing the
particular unlicensed medication for the indication requested are likely to
outweigh the possible risks. This decision will be taken on the basis of the peerreviewed evidence supplied by the prescribing consultant (see 5.4.7.1 above).
7.4.8.2
Requests to the DTC from prescribers to use an unlicensed medicine will be
reviewed by members of the DTC at the invitation of the DTC chair. Any request
for supply of unlicensed medications must be endorsed either by the chair of the
DTC or a member of DTC deputising for him/her.
7.4.8.3
The DTC will periodically review prescriptions of unlicensed medications within
the Trust.
7.4.9
Pharmacy Responsibilities
7.4.9.1
If a suitable alternative with an MA cannot be found, the pharmacy can be asked
to attempt to source the unlicensed product from a reputable supplier, from
whom adequate assurance of the quality of the product can be obtained.
7.4.9.2
The pharmacy will need to record the source of the medicine, the person to
whom it is supplied and the dates and quantities supplied on each occasion. Any
adverse reactions will also need to be recorded and records kept for inspection
by the MHRA for at least 11 years.
7.4.9.3
The medicinal product may not be dispensed by the pharmacy without the
relevant documentation having been completed and returned by the consultant.
7.4.9.4
The pharmacy will inform those administering the medicine of the unlicensed
status of the preparation and advise as necessary.
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7.4.10
Administering Responsibilities
7.4.10.1 The person administering the medicine must only use it for the patient named on
the label, unless it is supplied as a ‘stock’ item, in which case batch number and
expiry date must be recorded in the patient’s notes.
7.4.11
Trust Responsibilities
7.4.11.1 Provided that the procedures described above have been followed, prescribers
can expect the Trust to share liability for their use of unlicensed medications.
7.5.
Information for Patients
7.5.1
All patients must be involved in the planning of their treatment.
7.5.2
All treatment must be discussed with the patient and carer as appropriate.
7.5.3
Information must be provided for the patient as to the expected effects of the
medicine as well as any side effects, and the alternatives available. Wherever
possible, the manufacturer’s package insert or printed information must be
provided. In off-label use, some information in the manufacturer’s leaflet will not
apply to the indication for which the medication is being prescribed, which
should be explained to the individual.
Prescribers must use the patient information available on the choice and
medication website (http://www.choiceandmedication.org/wlmht/) whenever
possible or the trust intranet in the appropriate language for patients.
7.5.4
Patients must be advised to carry details of prescribed medication with them in
case of emergency.
8.
The pharmacist’s role
8.1
The Pharmacists’ role in ensuring safe, appropriate and accurate use of
medication. Pharmacists must operate in line with Royal Pharmaceutical
Society’s/General Pharmaceutical Council’s Code of Ethics and Practice
8.1.1
To ensure accuracy of the prescription on admission the pharmacist or an
accredited member of the pharmacy team will, whenever possible, check the
admitting doctor’s medication reconciliation against at least two alternative
sources.
8.1.2
To ensure the accuracy of all prescription the pharmacist must check that the
prescription is:
 Correctly written to avoid misunderstanding or error.
 Appropriate dose for the patient
 Suitable treatment for the individual
 Safe in that newly prescribed medicine will not dangerously nullify or interact
with the effect of any concurrently prescribed medicines or food
 Mandatory monitoring has been carried out prior to initiation
 Authorised under T2/T3/S62/CT01 if applicable
 Sign, in green pen, in the pharmacy box on the prescription chart to indicate
that a pharmacist has screened the medication to ensure it is safe and legal.
 All inpatient wards will have regular pharmacy visits to assess accuracy of
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
prescription charts.
All community/recovery teams will have 3 monthly pharmacy visits to assess
prescription charts.
The pharmacist is involved in procurement of medicines for hospital use,
advising on security and storage of medication, dispensing and supplying the
medicine in a form suitable for administration to the individual, and providing
relevant additional information. They may annotate the prescription, in green
pen, to render it clearer, endorse additional administration information and
advise on monitoring requirements. A pharmacy contact number must be
available for further discussion by other clinicians if necessary.
8.1.3
It is recognised that the transcription of prescription charts can lead to errors
and loss of information. To ensure the accuracy of rewritten prescription charts
the pharmacist will, whenever possible, carry out a transcription check to ensure
the prescription is correct and all relevant information is transcribed and will sign
and date the transcription check box on the prescription chart.
8.1.4
The pharmacist is involved in monitoring and reporting adverse side effects of
medicines, and must therefore be given any relevant information which the
administering practitioner identifies. Yellow Cards, found in the back of the BNF,
must be used to report relevant adverse events to the MHRA and an incident
reporting (IR1) form must be completed for these and medicine errors.
8.1.5
The pharmacist must sign and date any amendments made to a prescription
after consultation with the patient’s doctor, endorsing ‘pc’ (prescriber contacted)
in such an instance or ‘pnc’ if the prescriber was not consulted.
8.1.6
Medication must be supplied and delivered in sealed, tamper-proof bags or
boxes enabling those transporting them to be able to demonstrate safe delivery.
8.1.7
Filling of compliance aids, such as Dosette Boxes, must be carried out in
pharmacies – nurses cannot carry out this dispensing function unless assessed
competent to do so. The use of these is to be discussed on an individual basis
and they are only to be issued where the patient has been assessed and found
to be suitable and the prescribed medicines are suitable for storage in this way.
8.1.8
Pharmacists must make every effort to respond to prescribers’ enquiries in a
timely and comprehensive manner, providing contact details in case further
information is required.
8.1.9
Where there is disagreement between nursing and medical staff about
appropriateness of medication, the Accountable Clinician has the overall clinical
responsibility for patient care.
8.1.10
To ensure accuracy of medication information between care settings the
pharmacist must ensure that any discharge medication or short term leave
prescriptions are checked against the current inpatient chart to ensure
medication reconciliation at the point of leave and discharge from hospital, and
that the To Take Away (TTA) medication section on the back of the inpatient
chart is annotated with the date and number of days supply of the prescription.
8.1.11
Controlled Drugs held on wards must be checked by pharmacists every three
months in accordance with the controlled drugs policy and standard operating
procedures.
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9.
The supply of medication
9.1
Dispensing of medication
9.1.1
Dispensing is defined as the provision of medicines as specified on a lawful
prescription which can only be filled by a registered pharmacist, dentist or
member of the medical profession. Dispensing includes any amendment to a
previously dispensed supply or removal of medication supplied as stock to be
given to a patient for later administration. Nurses are not legally allowed to
dispense medication.
9.2
The supply of ward/department/community/recovery Teams stocks of regularly
used medicines
9.2.1
All wards, community/recovery teams, or other departments that use medication
regularly will have a stock list reflecting their current use of medication.
9.2.2
Inpatient wards will have a regular stock top up where a member of the
pharmacy team will check the current stock on the ward and order any
replacement stock required. Outside of this visit they may order additional stock
if required by requesting in their pharmacy communication book.
9.2.3
Community/recovery teams and other departments will have a stock list and will
place regular orders by faxing the completed stock list to the appropriate
pharmacy department.
9.2.4
The following items will NOT be allowed on stock lists: clozapine, unlicensed
medicines, eye drops, steroid or anti-biotic creams, chemotherapy, anticoagulants and other high risk medicines.
9.2.5
For supply of controlled drugs see controlled drugs policy and standard
operating procedures.
9.3
The Supply of Named Patient Medicines
9.3.1
Medicines not on the stock list will need to be supplied on a named patient
basis.
9.3.2
The pharmacist will need to screen any medicine that is supplied on a named
patient basis prior to dispensing.
9.3.3
Once screened by a pharmacist further supplies on named patient medicines
can be requested by a pharmacy technician.
9.4
Supply of Urgent Supplies of Medicine in Hours and Out of Hours
9.4.1
During normal working hours all requests for urgent supplies of stock or named
patient medicines should be made to the pharmacy team based on that site.
9.4.2
Out of hours any request for medication should be made via the unit coordinator.
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9.4.3
If the medication is available in the out of hours cupboard ‘GREEN’ list the unit
co-ordinator can authorise its release. If the medication is on the ‘RED’ List then
the on-call pharmacist must be contacted to authorise its release. If the
medication is not kept in the out of hours cupboard the on call pharmacist must
be contacted via the unit co-ordinator.
9.5
The availability in clinical areas of medicines that may be required in response to
an emergency
9.5.1
Each inpatient clinical area will hold stock of emergency medicines as agreed
with the acute trust response team for medical emergencies.
9.5.2
Each inpatient clinical area will have stock medication to manage acute medical
situations of anaphylaxis, seizure, hypoglycaemia, acute asthma attacks and
benzodiazepine overdose (See Managing medical emergencies guideline).
9.6
The supply of medication for inpatient transfers
9.6.1
Where an internal transfer of an inpatient occurs liaison with the new ward
should occur prior to transfer to arrange supply of medication as necessary.
9.6.2
Inpatients who are to be transferred to a different inpatient organisation should
have a discharge prescription completed; however liaison should occur with the
omitting hospital to ascertain medicine supply requirements.
9.7
The supply of discharge medication or short term leave
9.7.1
The majority of discharge and short term leave will be planned and where
possible medication should be ordered from pharmacy at least 24 hours.
9.7.2
Short Leave and discharge medication must be prescribed on the ‘medicines for
short term leave’ or ‘Discharge Prescription/7 day follow up’ (available as an
editable letter in RIO) prescription form respectively and must be screened by a
pharmacist prior to supply. The Discharge Prescription/7 day follow up MUST
be verified by a pharmacist before it is sent to the GP and/or given to the patient.
9.7.3
To allow for original pack dispensing and ensure patients receive patient
information leaflets on discharge a 28- or 30- day pack of each medicine is
usually given unless the prescription has been endorsed ‘EXACT QUANTITY
ONLY’ and then the requested amount will be supplied.
9.8
The supply of outpatient medication
9.8.1
Medication for outpatients under the care of community/recovery teams will be
prescribed on FP10 prescriptions and dispensed by the service users
community pharmacy of choice.
9.8.2
Clozapine is currently a hospital only medication and will be prescribed on a
clozapine outpatient prescription and dispensed by the Trust pharmacy. In
some areas nurses are authorised to release pre-dispensed clozapine to
outpatients once they have a valid blood test result as specified in the clozapine
clinic operational procedure.
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10
The administration of medication
10.1
Administration of medication
Administration of medication is a clinical intervention defined as preparing,
giving, and evaluating the effectiveness of prescribed medication.
10.2
Responsibility for the Administration of Medication
The administration of medicines is normally the responsibility of the registered
nurse, unless the doctor wishes to perform this in her/his own right, in which
case she/he takes responsibility.
Nurses have a statutory responsibility to administer medication in line with the
NMC Guidelines for the administration of medication. Medicines must be
administered by a registered nurse. ‘As a registered nurse you are accountable
for your actions and omissions. In administering any medication, or assisting or
overseeing any self-administration of medication, you must exercise your
professional judgment and apply your knowledge and skill in the given situation.
In addition, all registered nurses must know the therapeutic uses of the medicine
to be administered, its normal dosage, and be familiar with the side effects,
precautions and contra-indications outlined in the current edition of the BNF and
the package insert.
NMC Guidelines state: “The administration of medicines is an important aspect
of the professional practice of persons whose names are on the Council’s
register. It is not solely a mechanistic task to be performed in strict compliance
with the written prescription of a medical practitioner. It requires thought and the
exercise of professional judgment ...”.
The nurse should regularly monitor patients for adverse effects of medication
and take appropriate action.
Nurses must determine whether it is necessary or advisable to withhold
medicine pending consultation with the prescriber or a pharmacist, particularly
where the potential for an adverse event, illegal administration under the MH
Act, or interaction is identified, for example if the individual is under the influence
of alcohol. The appropriate code in the prescription chart must be used to record
the omission and a record made in the patient’s notes
10.2.1
Covert administration is only permitted in exceptional circumstances. (See
Procedure for the Covert Administration of medication). Any decision to
administer covertly must be discussed with the whole multidisciplinary team and
recorded in the patient’s notes.
10.2.2
Labels on appropriate containers of medicines are the responsibility of the
relevant pharmacy department and must not be altered by other staff.
10.2.3
The administration of medication may be carried out by a single registered
nurse. Student nurses may participate in the administration of medication under
the direct supervision of a registered nurse. Single nurse administration must be
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carried out in accordance with NMC guidelines on the administration of
medicines:
“Qualified nurses may administer medicines with a single signature any
Prescription Only Medication (POM), general sales list or pharmacy medicine
(NMC 2007), the NMC supports a single signature except for controlled drugs
when a secondary signature is required.”
Prior to administration the administering nurse must check that they have
selected the right patient, medication, dose, route, time and technique. The
nurse must ensure correct documentation following administration or nonadministration.
For high risk medicines e.g. methotrexate, insulin it is recommended that a
check from a second nurse is undertaken.
Service areas may decide to use two staff to support the administration of
medicines during medicine rounds. Where two nurses are involved the second
nurse should take the role of ensuring that there are no distractions for the
administering nurse and to support checking compliance.
In Broadmoor hospital due to particular service delivery requirements and
identified risks during medicine rounds the administration process must be
carried out by a registered nurse and in addition a second registered nurse or
healthcare assistant. The role of the second nurse (or health care assistant) is
to manage the immediate environment (prevent any distractions from other
patients) and to support the monitoring of medication compliance. Student
nurses may be involved in this process under direct supervision. The
administration of as required (PRN) medication may be carried out by a single
registered nurse.
10.2.4
The administering nurse is responsible for ensuring all documentation is
correctly completed prior to administration. (S)he must sign each prescription
chart after administration, ensuring that any refusals or omissions are
appropriately and legibly recorded, with the appropriate code and other
members of the clinical team informed.
10.2.5
As part of the learning experience, the role of the administering nurse may be
carried out by a student nurse under the supervision of a registered nurse, but
the latter must countersign the prescription chart and accountability still attaches
to the registered nurse.
10.2.6
When a nurse administers prescribed medication to a patient who is detained
under MHA 1983 and subject to the provisions of Part 4, s/he should ensure that
s/he is legally entitled to do so and that all legal requirements have been met by
checking the details of the consent form.
Where, although it is required, a Form T2 ,T3 or other appropriate form,
has not been completed, the administration of medicine for mental
disorder to a patient may constitute an assault, and therefore a civil wrong
and/or a criminal offence.
10.2.7
Where there is disagreement between nursing and medical staff about
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appropriateness of medication, the Responsible Clinician (RC) has the overall
clinical responsibility for patient care.
10.2.8
The Ward Manager/Clinical Co-coordinator/Clinical Nurse Manager must satisfy
themselves that agency or bank staff are competent to administer medication in
accordance with the NMC 'Guidelines for the Administration of Medicines' April
2002. The Manager needs to keep a record of staff training including all
refresher courses. The Bank Coordinator is responsible to ensure that all
Qualified Bank Nurses undergo this process and medication competency
workbooks are completed. The Senior Nurse/ Nurse in Charge delegating
medicine management responsibility to Qualified Agency Nurses needs to be
satisfied that the individual has an appropriate level of training and competency
to undertake medicine management.
10.3
Guidelines for the Administration of Medication
10.3.1
Medication must always be administered by direct reference to the patient's
prescription chart on which is written the patient's name and identification
number and the doctor's written, dated and signed prescription items.
10.3.2
Prior to administering medication the nurse(s) must take appropriate steps to
ensure the correct patient identification. E.g. checking patient’s date of birth.
10.3.3
Prior to administration the nurse must take reasonable steps to ensure the
prescription is legal i.e. that it is signed by a prescriber and allows lawful
administration under the MHA.
10.3.4
The list of ‘homely remedies/discretionary medicines’ on the back page must be
signed by a prescriber prior to administration of any of the listed medications.
Medicines not printed on the prescription for homely remedies or scored through
by the prescriber must not be administered under this section.
10.3.5
A patient’s privacy must be ensured during the administration of medicine.
10.3.6
Prior to the administration of medication, regular medication must be crosschecked with the ‘once only, 'as required' and ‘homely remedies/discretionary’
sections of the prescription chart to avoid duplication or repeated dosing.
10.3.7
Oral medicines must always be placed directly into a suitable medicine cup,
from which the patient can take it, hygienically and without touching it directly.
They must be given sufficient water with which to wash it down completely.
10.3.8
Liquid medication should be measured using an oral syringe.
10.3.9
All measuring and administration of insulin must be carried out using either an
insulin syringe or a commercial insulin pen device.
10.3.10
NMC guidelines state:
‘In exercising your professional accountability in the best interests of your
patients you must:
 Know the therapeutic uses of the medicine to be administered, its normal
dosage, side effects, precautions and contraindications.
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10.3.11
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10.3.12
Be certain of the identity of the patient to whom medication is to be
administered.
Be aware of the patient’s care plan.
Check that the prescription, and the label on medicine dispensed by a
pharmacist is clearly written and unambiguous.
Have considered the dosage, method of administration, route and timing of the
administration in the context of the condition of the patient and co-existing
therapies.
Check the expiry date of the medicine to be administered.
Check that the patient is not allergic to the medicine before administering it.
Contact the prescriber or another authorised prescriber without delay where
contra-indications to the prescribed medicine are discovered, where the patient
develops a reaction to the medicine or where the assessment of the patient
indicates that the medicine is no longer suitable.
Make a clear, accurate and immediate record of all medicine administered,
intentionally withheld or refused by the patient, ensuring that any written entries
and the signature are clear and legible; it is also your responsibility to ensure
that a record is made when delegating the task of administering medication.
Where supervising a student nurse or midwife in the administration of
medicines, clearly countersign the signature of the student’.
Prior to undertaking the administration of medications the nurse must ensure
that the following are in order:Trolley or injection tray and equipment checked if required.
Fresh drinking water available.
Where disposable cups are not available, plastic medicine cups have been
washed in hot soapy water.
Prescription charts for all patients as required (where appropriate, consent to
treatment form attached).
Signature of the registered medical practitioner.
The date that the prescription was commenced.
Specified stop or review dates.
Check the frequency – be careful for medicines that are not administered daily
e.g weekly, three times a week - calculate when the next dose is due and
ensure it is only given at the correct interval.
That the medication has not already been administered.
That fridge temperature has not been outside the 2-8 degree C range, before
administering refrigerated items.
The container and individual strip, expiry date, medication name, dosage,
strength and formulation.
Any endorsed special instruction e.g. with food, or contra-indications e.g. pulse
rate for digoxin.
Dosage calculations.
The patient’s weight if relevant to dose calculation.
That the prescribed formulation is available e.g. when tablets need crushing.
Adverse reactions following administration of medication must be reported to
the medical practitioner immediately and subsequently on an incident form (IR1),
Yellow Card – found in the back of the BNF, and to the area’s pharmacist.
Defective medicines and materials should be reported to the supplying
pharmacy department.
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10.3.13
If a dose is omitted by the nurse or refused by the patient, this must be recorded
on the prescription chart, using the appropriate code, a note made in the
patient’s notes and the Ward Manager /person in charge and AC informed.
10.3.14
If the dose is not administered because it is out of stock the medication must
be ordered from the pharmacy at the earliest opportunity. If it is outside of
pharmacy hours, the doctor must decide whether the medication is needed
before the pharmacy re-opens. Pharmacists can be contacted through the
switchboard out-of- hours.
10.3.15
If it is considered necessary to administer ‘as required’ medication, the reason
for this must be fully documented by the administering nurse in the patient’s
notes. Subsequently an entry must be made as to whether the medicine was
effective.
10.3.16
Any unused doses of medication, ‘sharps’ and broken ampoules (except
Controlled Drugs) must be disposed of in the blue lidded yellow cin bins. For
management of controlled drugs see Administration of Controlled Drugs – see
controlled drugs policy and standard operating procedures.
10.4
Guidance on timeliness of medicine administration and actions if a dose of
medicine is omitted or significantly delayed
10.4.1
Medication should always be given in a timely fashion i.e. as close to the
prescribed time as possible.
10.4.2
Information should be clearly documented in each patient’s medication care
plan on actions to be taken if medication is delayed or omitted due to any
reason.
10.4.3
Medications listed on the critical list should not be significantly delayed or
omitted (unless on the instructions of a prescriber, due to concerns by nursing
team or due to patient refusal).
10.4.4
If medications on the critical list are significantly delayed (unless on the
instructions of a prescriber, due to concerns by nursing team or due to patient
refusal) an incident from must be completed detailing the reasons for the delay
or omission.
10.5
Administration of Controlled Drugs – see controlled drugs policy and standard
operating procedures.
10.6
Supervised Self-Administration: See Procedure for Self-Administration of
Medication to inpatients.
10.6.1
Where an individual is unable to self-administer medication or where the
medication requires preparation e.g. insulin, supervision of medication must be
considered.
10.6.2
The patient will administer his or her own medication under the supervision of a
trained nurse over a defined period of time as agreed by the team. This can be
done either on the ward or in the community following the self-administration
procedure.
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10.7
Self – Administration: See Procedure for Self-Administration of Medication to
inpatients.
10.7.1
Both the responsible medical staff and named nurse / key worker must be in
agreement that the patient is capable of managing his/her own medication, and
that it is in his/her best interest, prior to any decision being taken on the
patient’s self-administration. The details of the decision must be documented in
the patient’s notes and a prescription chart, specifying the number of days’
supply agreed upon.
10.7.2
Self-administration may be carried out on the wards and in the community: the
former may be appropriate for pre-discharge planning, provided suitable, secure
individual storage areas are identified and access to keys is carefully
considered. Patients will be required to accept responsibility for such storage
and security, which should be spot-checked intermittently by clinical staff.
10.7.3
All medication will be fully and clearly labelled by the pharmacy with the
patient’s name, medication name, dosage and frequency to be taken, as well as
the route of administration, where necessary.
10.7.4
All containers must be child-proofed. The pharmacy must be involved in this
process and carry out the dispensing. Labels and contents must not be altered
in any way.
10.7.5
The allocated nurse is responsible for ensuring that the medication is taken as
prescribed, that the safety and security of the medication is maintained, and that
there is a sufficient supply.
10.7.6
The treatment plan must be reviewed regularly to assess the suitability of the
individual for self-administration and to ensure appropriate quantities are being
dispensed.
10.7.7
The allocated nurse has a responsibility to ensure that any unused medication is
returned to pharmacy.
10.7.8
Medication dispensed as TTA’s must be checked for accuracy against the
patient’s prescription by a suitably qualified member of staff before being
handed over, and discussed with the patient or their carer.
10.8
Intramuscular Injection
NB: staff administering parenteral medicine must be Immediate Life
Support trained.
NMC guidance states “it is unacceptable to prepare substances 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. In an
emergency, where you may be required to prepare substances for injection by a
doctor, you should ensure that the person administering the medicine has
undertaken the appropriate checks as indicated above”.
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10.8.1
There must always be consideration for the privacy and dignity of the individual
receiving injectable medication and a risk assessment of the most suitable
person to give it. Wherever possible there should be the choice of having
injections administered by a professional of the same gender and if this is
not possible, there must be a chaperone available.
10.8.2
An intramuscular injection administers a medication
 Into a muscle so that it can be readily absorbed.
 In a larger quantity of fluid than can be administered subcutaneously:
maximum 3ml in any site.
 When a patient can’t or will not take medication orally.
 When it cannot be absorbed from the intestine i.e. paralytic ileus.
 To a patient who is unconscious.
 Which is only available in this form.
 Which may be destroyed by gastric juices.
 Which is required to be long-acting i.e. a depot.
10.8.3
Wherever possible two registered nurses must be present during the
preparation of an intramuscular injection. Community Psychiatric
Nurses (CPNs) working alone may be required to administer
depots to
patients in their homes – this must be done in line with NMC guidelines.
NMC (2007) guidelines support single signature administration for nurse
registrants assessed as competent.
10.8.4
An appropriate needle size must be used which is dependent on the site of
injection and body mass of the patient. The needle should be long enough to
reach the muscle without penetrating underlying structures.
10.8.5
If a needle is supplied with the medication this should be used.
10.8.6
If patient is having regular injections the site of injection must be regularly
alternated to reduce risk of local adverse effects.
10.8.7
Deltoid injection site may be used for medicines that are licensed for this route of
administration. Staff must have undertaken training on deltoid administration
prior to administering to patients.
10.8.8
Best Practice Points Administering I.M. depot or Long Acting Medication
The patient should be positioned so as to relax the muscle.
The ‘Z track’ technique should be used at all times.
The Z-track method of IM injection prevents leakage (tracking) into the
subcutaneous tissue and is the technique of choice for giving IM injections.
The medication is locked in and discomfort, pain, tissue irritation and abscess /
nodule formation caused by leakage of medication into subcutaneous tissue is
minimised.
10.8.9
Z-TRACK TECHNIQUE FOR IM ADMINISTRATION
• Locate the most suitable injection site
• The service user may lie down or stand, according to their preference
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• Hands should be cleaned and the injection site disinfected in line with infection
control procedures. It is advisable to wear disposable gloves.
• To begin, use the non-dominant hand to pull the skin and subcutaneous tissue
two – three centimetres away from the injection site
• Hold the needle at right angles (90 degrees) to the skin
• Insert the needle quickly, penetrating the muscle and leaving about a third of
the needle exposed
• Pull back the plunger to observe for blood aspiration. If blood is aspirated, the
procedure should be discontinued withdraw the needle, discard and prepare
injection once again. Use a different site for injection, pull black plunger and
check again.
• If no blood is aspirated, slowly and continuously inject the medication.
• After a couple of seconds, withdraw the needle quickly at the same angle to
which it went in.( Where using retractable needles they will automatically
retract).
• Finally, release the skin, allowing the layers to return to their normal positions.
Do not massage the injection site.
• Where appropriate use a hypoallergenic plaster to prevent any oozing from the
injection site ensuring the patient is not allergic.
10.8.10
Observe the patient for the efficacy of the medication or any adverse effects.
Complications of IM injections should also be monitored for including:
abscess, nodules, tissue damage, haematoma, swelling, infection, injury
to blood vessels, bones and peripheral nerves, fat embolism.
10.8.11
If the medication is administered whilst the patient is being restrained,
special physical observation requirements apply. Patients must be observed
closely during any restraining intervention, to reduce the risk of local bruising,
pain or extravasations. Particular care must be taken under these
circumstances to ensure that IM medicines are administered in the correct
site. If it has been assessed as being too difficult to administer medicines
safely at that time a decision needs to be made to ensure that this is only
carried out when it is safe to do so.
See Rapid Tranquilisation Policy. R10
10.9
Intravenous Injection
10.9.1 Intravenous administration is not normal practice in WLMHT. Where there is a need
for such administration, arrangements for appropriate training and competence
need to be agreed.
10.9.2
In exceptional circumstances such as for managing complications of pandemic
influenza, or other situations which may require the use of intravenous
medication advice will be issued via the Medicines Management Group to
appropriately trained staff
10.10 Subcutaneous and intradermal administration and immunisation
See Vaccinations and Immunisation Policy on the N drive.
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10.11 Patient Group Directions (PGDs)
Patient Specific Directions can be written by independent prescribers to instruct
other professionals to supply or administer medicines to a specific patient.
Alternatively, PGDs can be used to enable specified healthcare professionals to
supply and administer medicines to a group of patients that fit the criteria laid
out in the PGD, without the need for a prescription or instruction from a
prescriber. Healthcare professionals working with PGDs require no additional
formal qualification; however the Trust is responsible for ensuring they are *fully
competent and trained on the use of the PGD.*
For more information see http://www.npc.co.uk/publications/pgd/pgd.pdf
PGDs must be developed in conjunction with the Medicines Management Group
and signed off by the Chief Pharmacist WLMHT, a senior doctor and Head of
Nursing.
11
The storage, transport and disposal of
medication
11.1
The system for secure storage of medications on wards is the responsibility of
the Clinical Nurse Manager/Ward Manager for that ward area.
11.2
Clinic rooms are intended primarily for the storage and preparation of medicines
and not for the treatment of patients. However, if there is nowhere else
available for treatment of patients, all medication cupboards must be kept
locked while the room is used for this purpose
Oral medication should be administered over a stable door, both sections of
which are to be kept locked shut when the room is not in use.
The room temperature must be maintained below 25 degrees C for safe storage
of medication other than that intended for refrigeration. Room temperature must
be monitored and documented by the nursing staff at least once daily
11.3
All medication fridges must have a minimum/maximum thermometer and be
approved by the Pharmacy Department. Medication fridge temperatures must
be maintained between 2 and 8 degrees C. Maximum, minimum and current
temperatures must be monitored and documented by the nursing staff at least
once daily; specimens and food must not be stored in the medication fridge.
11.4
All medication cupboards and fridges must be of a suitable specification (Duthie
Report). Medicines Trolleys are not recommended for use. Cupboards must be
securely locked or bolted to a strong wall. Fridges must be hardwired.
11.5
Medication cupboard keys must be kept separate from other keys and in the
possession of a registered nurse at all times, except in community centres
where they can be stored in a small safe or key press.
The medicine keys must be accounted for at each handover of shifts
11.6
A spare set of medication keys must be available for ward staff in the event of
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loss or damage to medication keys; the location of the spare keys will be agreed
locally with the Head of Nursing/CNM/Ward Manager and Head of Service/
Service Director.
11.7
For management of Keys for the Controlled Drugs cupboard please refer to
controlled drugs policy and standard operating procedures.
11.8
Where self-administration is being carried out on the wards, each patient must
have a lockable drawer or cupboard in their room for safe storage. They must
be reminded that it must remain locked at all times outside medication times,
and of their responsibility for the safe-keeping of the key. See section 8.6 and
8.7
11.9
It is normal practice for CPNs to transport medication to individuals they are
visiting at home. In these circumstances, the items must have been prescribed
for the individual. Stock supplies can be used if the medication is to be
administered by the CPN, however if medication is to be left with the patient it
must be dispensed for the individual and the label must include administration
instructions. Medication transported by CPNs should be carried in a secure
bag and must never be left in an unattended vehicle at any time. Each medicine
carried should be accompanied by the written prescription or prescription chart.
11.10
CPNs must always carry ‘photocard’ identification with them.
11.11
Medication transported around or between sites must be carried in sealed
pharmacy bags or boxes, and delivery and receipt must be signed for by a
member of WLMHT staff.
11.12
For transport of Controlled Drugs please see controlled drugs policy and
standard operating procedures.
11.13
Medications that require refrigeration must be transported following the
Standard Operating Procedure: Cold Chain Transport And Handling Of
Vaccines.
11.14
Medicines must be disposed of in accordance with the relevant Hazardous
Waste legislation and regulations and the Trust Waste Policy. The majority of
medicines should be disposed of in a 22 litre blue pharmaceutical container with
a blue label and a blue lid, however cytostatic and cytotoxic medicines must be
disposed of into purple-lidded bins. Controlled Drugs must be disposed of in
accordance with the controlled drugs policy and standard operating procedures.
For more information on specific medicines contact the nearest site
Hospital Pharmacy department.
11.15
Expired and patients’ own medicines requiring destruction (except controlled
drugs, which are managed by pharmacy staff) must be destroyed on site into
appropriate bins, not transported between sites. Medicines suitable for reuse
and return to pharmacy must be removed by pharmacy staff to the nearest
pharmacy dispensary.
12
12.1
Medication brought in by patients
Patients’ own medication must be recorded on admission in the patient record
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and used to assist with Medicines Reconciliation. Where appropriate for reuse
(see Trust guidance), it should be used on the ward for administration with
patients consent, or it can be returned with family members. However, any
changes in treatment while admitted must be conveyed to ensure discontinued
medications at home are taken for destruction at a pharmacy.
12.2
The Trust encourages the re-use of ‘Patients Own Drugs’ (PODs) and returned
TTA’s as long as they meet the criteria for re-use (Link). All patients’ own
medication must be stored in a locked cupboard: if it is not to be used on the
ward, it must be kept apart from ward medication.
12.3
For POD Controlled Drugs see the controlled drugs policy and standard
operating procedures.
12.4
On discharge, the named nurse/key worker must discuss the prescribed
medication with the patient as well as any changes to his/her previous
medication. The patient’s own medication remains their property and must be
returned unless permission is obtained to destroy it.
12.5
Advice must be given on the importance of getting rid of any other medication
which is not currently prescribed that may be at the patient’s home, preferably
by taking it to a pharmacy.
12.6
Patient own medication which is not labelled with the patients name will be
destroyed.
12.7
Patient own medication which has not been collected form the ward within two
weeks of discharge will be deemed no longer required and be destroyed.
13
Assessment of nurses
13.1
The ward manager/ clinical nurse manager must satisfy themselves that all
registered nurses are competent to administer medication in line with this Trust
Policy and NMC Guidelines. This process will be supported by the supervision
and appraisal processes. The Competency Handbook has been developed for
this purpose and should be used in secondary induction for new staff.
14
Training
14.1
Training on medicines management policies, procedures and guidelines will be
included in medicines management training and will be delivered in line with the
training matrix as outlined in the mandatory training policy.
14.2
Compliance with training will be monitored in regular management supervision.
M12 Mandatory Training Policy will be followed for staff who persistently fail to
attend training.
15
Monitoring
15.1
The monitoring if the medicines policy and associated polices and procedures
will be monitored by the Trusts Medicines Management Group.
15.2
Outcomes from monitoring of the medicines policy and associated polices and
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procedures will be reported to the Clinical Effectiveness & Compliance
Committee.
15.3
The Clinical Effectiveness and Compliance committee will report Medicines
Management Outcomes to the Trust Board.
15.4
Compliance with the medicines policy and associated polices and procedures
will be monitored through a number methods including audit as outlined in the
monitoring template.
15.5
Where poor compliance is highlighted the lead for that ward/department will be
required to develop and action plan to address these areas which will need to
be reported to the Medicines Management Group.
16
Glossary of terms/acronyms
AC
BNF
CD
CDs
CPNs
CSU
DTC
eBNF
ECG
GMC
GPhC
MA
MDT
MHA
MHRA
NKDA
NMC
NMP
NPSA
PC
PGDs
PIL
Pnc
PODs
POM
Prn
rINN
RIO
RCPsych
RPS
RRR
SOAD
Approved Clinician
British National Formulary
Clinical Director
Controlled Drugs
Community psychiatric nurses
Clinical Service Unit
Drugs and Therapeutics Committee
electronic British National Formulary
electrocardiogram
General Medical Council
General Pharmaceutical Council
Marketing Authority (product licence)
Multi-disciplinary team
Mental Health Act
Medicines and healthcare products regulatory agency
No Known Drug Allergy
Nursing and Midwifery Council
Non-Medical Prescribing
National Patient Safety Agency
prescriber contacted
Patient Group Directions
Patient information leaflet
prescriber not contacted
Patient own drugs
Prescription only medication
when required
recommended International Non-proprietary name
Electronic patient record
Royal College of Psychiatrist
Royal Pharmaceutical Society of Great Britain
Rapid Response Report
Second opinion approved doctor
SPC
Summary of Product Characteristics
TTA
To Take Away Medication
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17
NPSA/NHS England guidance and alerts
17.1
17.2
All relevant alerts and their actions will be documented on the medicines
management page of the exchange.
All prescribers, pharmacy staff and nurses must be aware of any NPSA/NHS
England guidance that relates to their current practice and follow the trusts
recommendations for action.
18
References and further recommended reading
A Spoonful of Sugar, medicines management in NHS hospitals – Audit Commission (2001)
http://archive.auditcommission.gov.uk/auditcommission/sitecollectiondocuments/AuditCommissionReports/NationalS
tudies/nrspoonfulsugar.pdf
A Vision for Pharmacy in the new NHS: DH 2003
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Consultations/Closedconsultations
/DH_4068353
British National Formulary (BNF) current edition
https://www.medicinescomplete.com/mc/bnf/current/
Building a safer NHS for Patients – Improving medication safety DH 2004
http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_d
h/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4084961.pdf
Choosing health through Pharmacy – A programme for pharmaceutical public health: 2005-2015:
DH April 2005
http://www.rcn.org.uk/downloads/professional_development/mental_health_virtual_ward/treatmen
ts_and_therapies/choosing-health-through-pharmaciespdf.pdf
Controlled Drugs (Supervision of Management and Use) Regulations 2006. SI 2006/3148
http://www.legislation.gov.uk/uksi/2006/3148/made
CQC – Controlled Drugs guidance http://www.cqc.org.uk/content/controlled-drugs
CQC – Managing patients’ medicines after discharge from hospital 2009
CQC –Specialist Mental Health Services Provider Handbook (2014)
http://www.cqc.org.uk/sites/default/files/20140925_mental_health_provider_handbook_main_final.
pdf
Equity and excellence: Liberating the NHS (DOH 2010)
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213823/dh_117794
.pdf
Getting the Medicines Right: Medicines Management in Adult and Older Adult Acute Mental
Health Wards National Mental Health Development Unit (2009) http://www.cmhp.org.uk/wpcontent/uploads/2013/02/getting-the-medicines-right-jul-2009.pdf
Getting the Medicines Right 2: Medicines Management in Mental Health Crisis Resolution and
Treatment teams National Mental Health Development Unit (2010) http://www.cmhp.org.uk/wpcontent/uploads/2013/02/Getting-the-medicines-right-2-final-pdf.pdf
Good practice in prescribing and managing medicines and devices. (GMC 2013) http://www.gmcuk.org/guidance/ethical_guidance/14316.asp
Health Act 2006 http://www.legislation.gov.uk/ukpga/2006/28/contents
High Secure Psychiatric Services (Arrangements for safety and security at Ashworth, Broadmoor
and Rampton Hospitals) directions
Keeping Patients safe when they transfer between care providers – getting the medicines right
(RPS 2009) http://www.rpharms.com/current-campaigns-pdfs/rps-transfer-of-care-final-report.pdf
Medicines Act 1968 and subsequent revisions
http://www.legislation.gov.uk/ukpga/1968/67/contents
Medicines Optimisation: Helping patients to make the most of medicines (RPS 2013)
http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-theirmedicines.pdf
Mental Capacity Act 2005 and its Code of Practice
West London Mental Health NHS Trust
Policy M2 First date of issue: Sept 2005
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https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224660/Mental_Ca
pacity_Act_code_of_practice.pdf
Mental Health Act 1983 and MHA Code of Practice, and subsequent amendments
http://www.lbhf.gov.uk/Images/Code%20of%20practice%201983%20rev%202008%20dh_087073
%5B1%5D_tcm21-145032.pdf
NHSLA Risk Management Standards – includes aspects of Medicines Management
http://www.nhsla.com/safety/Documents/NHSLA%20Risk%20Management%20Standards%2020
12-2013.pdf
NICE Guidelines www.nice.org.uk
NPSA Alerts and RRRs, NHS England Patient Safety alerts
http://www.npsa.nhs.uk/
http://www.england.nhs.uk/ourwork/patientsafety/psa/
Nursing and Midwifery Council (NMC) standards for medicines http://www.nmc-uk.org
The Safe & Secure Handling of Medicines: A Team Approach. A revision of the Duthie Report
(1988) led by the Hospital. Pharmacists' Group of the RPS http://www.rpharms.com/supportpdfs/safsechandmeds.pdf
Standards of conduct, ethics and performance (GPhC 2012)
http://www.pharmacyregulation.org/standards/conduct-ethics-and-performance
Talking about medicines: managing medicines in mental health trusts (Healthcare Commission
2007)
http://www.starwards.org.uk/%3Fwpdmdl%3D15%26ind%3D2&rct=j&frm=1&q=&esrc=s&sa=U&ei
=HhWtVLaqO4vfaI2cgJgI&ved=0CB4QFjAC&sig2=uXHEam3HY3Qz2_DESoftxg&usg=AFQjCNF
rdeEnWwMVuyhA7vrOSayWvbT0lQ
The Misuse of Drugs (Safe Custody) Regulations 1973, amended 2007
http://www.legislation.gov.uk
The Misuse of Drugs Regulations 2001 2001/3998 http://www.legislation.gov.uk
Consensus Statement on high-dose antipsychotics (RCPsych 2014)
http://www.rcpsych.ac.uk/files/pdfversion/CR190.pdf
The Royal Marsden Hospital Manual of Clinical Nursing Procedures
Use of licensed medicines for unlicensed applications in psychiatric practice (RCPsych 2007)
http://www.rcpsych.ac.uk/files/pdfversion/cr142.pdf
White paper – Pharmacy in England: building on strength – delivering the future DH 2008
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/228858/7341.pdf
West London Mental Health NHS Trust
Policy M2 First date of issue: Sept 2005
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