Medicine security
ward/department checklist
A checklist for each ward/department that holds medicines
Tackling fraud and managing security
Name of ward/department _______________________________________
Recommended measures for wards/departments
Yes No N/A
1. Receipt
1. Are measures in place to ensure that medicines are received by
authorised staff (registered healthcare professional) when
delivered to a ward/department?
2. Is there a process in place for checking the medicine delivery
order before it is locked away?
3. Is there a process in place, outlining staff actions to be taken and
who should be notified, when dealing with discrepancies in
medicine orders received?
4. Is there a process in place for the review and validation of
authorised signatories for those staff that can order medicines?
2. Storage
5. Are appropriate security measures applied to the storage of the
medicines below? (for each medicine, please tick the appropriate
response)
o
CDs
o
Internal medicines
o
External medicines
o
Refrigerator/freezer medicines
o
Intravenous fluids and sterile topical fluids
o
Flammable liquids and medical gases
o
TTOs/TTAs
o
Emergency medicines (crash trolleys/anaphylaxis kits)
3. Access
6. Are all cupboards, closed storage units (i.e. with doors) and
refrigerators in which medicines are stored lockable?
7. Are keys providing access to medicine cupboards in the
possession of an authorised person or securely stored at all times
and easily traceable?
8. Are doors leading to security sensitive areas where medicines are
stored access controlled?
2
NHS PROTECT – JANUARY 2014
Recommended measures for wards/departments
Yes No N/A
9. Where PIN codes are used as part of the access control system,
are the codes to the doors changed regularly1?
10. Is there a SOP for the management of out-of-hours medicine stock
to ensure content (stock levels/usage) reflects need?
5. Medicine waste and disposal
4. Patient own medicines
11. Is there an audit process in place to monitor the out-of-hours
SOP?
12. Is there a SOP for managing medicines that patients bring into
hospital?
13. Is information and advice provided to self-administering patients
on keeping their medicines secure?
14. Are patients’ own CDs stored securely and separately to ward CD
stock?
15. Is patient consent obtained prior to the destruction and disposal of
patients’ own CDs and medicines (not returned to the pharmacy)?
16. Are out-of-date medicines and any stock no longer required stored
securely until they are returned to pharmacy for safe disposal?
17. Are out-of-date medicines and any stock no longer required
returned to pharmacy securely?
18. Is there provision for the secure disposal of individual or part
contents of ampoule doses of CDs which are prepared but not
administered?
19. Are records kept when only part of the contents of an ampoule
containing CDs is used or there is a spillage of liquid CD
preparation?
1
Regularly and regular basis: at intervals of sufficient frequency to ensure that discrepancies can be identified in a timely way.
The frequency of such checks should be determined locally after a risk assessment has been carried out.
3
NHS PROTECT – JANUARY 2014
6.Reporting
20. Are all incidents involving security breaches reported to the
LSMS?
21. Where security breaches involve CDs, are these reported to the
CDAO?
General:
Use this area to report on any other areas of security risks and to provide further
information on any of the numbered responses.
Assessment carried out by
Job title
Date of assessment
4
NHS PROTECT – JANUARY 2014