PHARMACY
Standard Operating Procedure
CONTROLLED DRUGS: DESTRUCTION
Purpose
To ensure Controlled Drugs are destroyed in line with current legislation.
Scope
The procedure covers the process for the destruction of Controlled Drugs, and the recording
of their destruction.
Procedure
P1. Out of date CDs
Out of date CDs are usually identified during routine monthly stock checks
 Arrange for the pharmacist to check the expiry date and check whether more stock
needs to be ordered, and/or whether stock levels need adjusting
 Out-of-date CDs should be segregated from in-date stock. Expired stock should be
placed in a bag clearly labelled ‘Out-of-date awaiting destruction by authorised
witness’ (this is usually the responsible person delegated by the health board or
Area Team)
 Out of date CDs must not be ‘entered out’ of the CD register and must be included in
any routine balance checks until destruction occurs
 CDs must be destroyed in the presence of an authorised witness
 When the authorised witness visits, bring the out-of-date stock to their attention
 Obtain the keys to the CD cabinet from pharmacist and remove the out-of-date
stock
 Recheck expiry dates on all stock to be destroyed before destruction occurs
 Double check the quantity to be destroyed.
P2. Returned CDs
Please see the Pharmacy SOP: CD: Returns
P3. Destruction
 The person destroying the CDs must wear appropriate protective clothing (gloves,
apron and mask etc)
 CDs are denatured using CD Destruction kits. To destroy patches the backing should
be removed and the patch folded back onto itself. For all other medication use a
Controlled Drugs Destruction Kit, following the instructions:
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Crush/break ampoules and tablets
Add powders direct
Add liquids direct
Fill to capacity with water, shake well and contents will congeal in about five
minutes. The container is then added to the normal Doop bin. Cat litter may be
used for liquids.
PHARMACY
Standard Operating Procedure
CONTROLLED DRUGS: DESTRUCTION
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The CD Destruction kit (with denatured drug) should be placed into the appropriate
disposal container in the pharmacy
Dispose of gloves, apron etc.
Order CD Destruction Kit to replace one(s) used.
P4. Recording the destruction
 The record sheets for the destruction of CDs are kept inside the CD cupboard – these
should be completed for each CD and signed by both parties (including the
authorised witness to the destruction).
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When the out-of-date Schedule 2 CDs have been destroyed, an entry is made in the
CD register.
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For Schedule 3 CDs an entry is made on the record sheets kept inside the CD
cupboard. Both records signed by both parties detailing the:
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Name of drug
Quantity, strength and form
Batch number if possible
Name and address of patient
Date received
Date destroyed
Name and signature of person destroying CD
Signature of witness
Authority of witness (professional title)
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Check the remaining stock of Schedule 2 CDs and enter the resulting balance after
destruction into the register
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Ensure authorised witness signs register to confirm new balance is correct.
Responsibility
All pharmacists and dispensers have this responsibility but must have an authorised person
present before proceeding. Doctors may be present with the authorised person.
Review procedure
This procedure will be reviewed following:
 Changes in the law affecting dispensing
 Changes in the law affecting Controlled Drugs
 Changes in DDA or other guidelines affecting the dispensing process
 Change of staff
PHARMACY
Standard Operating Procedure
CONTROLLED DRUGS: DESTRUCTION
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Any adverse dispensing incident
In the absence of any of the above, on or before the date shown below.
Known risks
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Illness/lack of focus/personal problems
Over-reliance on accuracy of person who is recording the destruction of controlled
drugs
Self-checking
New staff.
I have read and understood this standard operating procedure.
Date
Name
Date of Preparation:
DUE:
Prepared by:
Signature:
Version number:
Signature
Date review takes
place and initials