Emergency Anaesthetic Controlled Drug Pack Standard Operating Procedure for Assembly
Version:
1
Approval Committee:
Formulary and Medicines
Date of Approval:
16 January 2015
Lead Job Title of originator/author:
Emergency Department Pharmacist
Date issued:
26 February 2015
Review date:
31 January 2017
Target audience:
Emergency Department/Critical Care Staff
Key words:
Emergency, RSI, Resuscitation
Main areas affected:
Emergency Department
Summary of most recent changes:
N/A
Consultation:
As above
Number of pages:
7
Type of document:
Standard Operating Procedure For
Emergency Department
Is this document to be published in any
other format?
No
The Trust strives to ensure equality of opportunity for all, both as a major employer and as a
provider of health care. Fairness and consistency for all those covered by this document has
therefore been considered, regardless of their individual differences.
Page 1 of 7
Contents
1
Introduction
3
2
Scope
3
3
Purpose
3
4
Definitions
3
5
Related Trust Policies
4
6
Roles and Responsibilities
4
7
Assembling the Emergency Anaesthetic Drug Pack
4
8
Using the Emergency Anaesthetic Drug Pack
5
9
Implementation
6
10
Process for Monitoring Compliance/Effectiveness
6
11
Arrangements for Review of the SOP
6
12
References
6
Appendix
Contents of the Emergency Anaesthetic Drug Packs
7
Page 2 of 7
1.
Introduction
In the Emergency Department, one adult Emergency Anaesthetic Drug Pack (EADP)
is kept for emergency anaesthesia when required. Currently this does not contain any
controlled drugs that may be required.
At the Major Trauma Centre Emergency Department at Southampton General Hospital
two anaesthetic drug packs are kept in the Emergency Department for emergency
anaesthesia when required. One of these contains controlled drugs, stored within the
controlled drug cupboard, the other non-controlled drugs. This has reduced the time
taken to obtain and prepare drugs for the administration of emergency anaesthesia in
critically ill patients.
To improve the efficiency of obtaining and preparing drugs for emergency anaesthesia
in the Emergency Department and to provide a more consistent approach across the
region for rotational medical staff, two drug bags following this above format are to be
introduced into the Emergency Department of this hospital.
The two drug packs consist of a fridge box containing non-controlled drugs (containing
Propofol, thiopentone, suxamethonium, rocuronium, vecuronium, metaraminol and
ephedrine) and a new controlled drug bag (containing ketamine, fentanyl and
midazolam) which will be stored in the Controlled drug cupboard.
This SOP will focus on the assembly of the EADP controlled drug pack and the
documentation required to adhere with the PHT Medicines Management and
Controlled Drugs policies.
2. Scope
This policy applies to the Emergency Department who will be responsible for
assembling the controlled drugs emergency anaesthetic drug pack, maintaining
accurate records, recording the use of the pack and ensuring reassembly once the
pack has been used.
3. Purpose
The purpose of this document is to describe the Standard Operating Procedure for
assembling the emergency anaesthetics drug pack which contains the controlled
drugs, ensuring that the medicines policy is adhered to.
4. Definitions
Standard Operating Procedure (SOP):
A SOP is a set of instructions to be followed in carrying out a given operation, or in a
given situation, which lend themselves to a definite or standardised procedure without
loss of effectiveness.
Emergency Anaesthetic Drug Pack (EADP):
These are packs that will have been pre-prepared to ensure the Critical
Care/Emergency Department team have what they require to sedate and intubate a
patient.
Controlled Drugs (CDs):
These are drugs that are supplied under the Misuse of Drugs Act 1971 and are subject
to documentation and storage regulations.
Page 3 of 7
5.
Related Trust Policies
 PHT Medicines Management Policy
 PHT Controlled Drugs Policy
6.
Roles and Responsibilities
It is the responsibility of the nurse in charge to arrange assembly of the EADP, maintain
accurate documentation in the ward CD register and in the EADP register. Once the
pack is used it is also the responsibility of the nurse in charge to ensure the EADP
register is completed and arrange assembly of the new pack.
7. Assembling the Emergency Anaesthetic Drug Pack:
7.1 Assemble the drugs needed for the EADP pack
Drug
Ketamine
Midazolam
Fentanyl
Strength
10mg/ml
1mg/ml
50 micrograms/ml
Pack Size
200mg/20ml vial
5mg/5ml ampoule
100microgram/2ml ampoule
Quantity
1
1
1
7.2 For each controlled drug, enter the drug out of the ward CD register and enter it in to the
EADP register. See example below:
7.2.1 Ward CD Register Entry:
Name, Form of Preparation and Strength: Midazolam Injection 1mg/ml (5mg/5ml) ampoule
Date
Time
16/07/13
14:00
17/07/13
09:00
Patient’s Name
Amount Given
Received from
pharmacy
1 x 5mg/5ml ampoule transferred to Emergency
Anaesthetic Drug Pack
JSmith
Witnessed
By
(Signature)
LBrown
MJones
JSmith
Given By
(Signature)
Stock
Balance
10
9
7.2.2 EADP Register Entry:
Enter all drugs in the pack into the EADP register, starting a new page each time the
bag is restocked, documenting both the batch numbers and expiry dates. See example
below:
Name, Form of Preparation and Strength:
Emergency Anaesthetic Drug Pack Tag No. 5532B Expiry 05/2014 (shortest expiry in bag)
Date
Time
17/07/13
09:00
18/07/13
21:00
Patient’s Name
Amount Given
Given By
(Signature)
Witnessed
By
(Signature)
Stock
Balance
Ketamine10mg/ml (200mg/20ml) vial BN: XYZ
EXP: 07/2014
Midazolam 1mg/ml (5mg/5ml) ampoule BN: LMN
EXP: 05/2014
Fentanyl 50 microgram/ml (100microgram/2ml)ampoule BN:
RPQ EXP: 03/2015
Assembled by:
M Jones
JSmith
1
M Jones
JSmith
1
M Jones
JSmith
1
MJones
JSmith
EADP Bag Seal checked and Correct
LBrown
THarvey
Page 1
Page 4 of 7
Once the pack has been assembled, seal the pack with a tamper-evident numbered tag
and record the tag number in the EADP register. See example above.
The EADP will need to be checked daily to ensure the seal remains in place and the
contents are still in date. This check needs to be recorded in the EADP register. See
example above.
8
Using the Emergency Anaesthetic Drug Pack
8.1
Once the pack is opened, the nurse in charge must ensure that details of the drugs
used are recorded in the EADP Register.
8.2
The date, time, patient name, drug, dose given and any wastage needs to be entered
and co-signed either by two nurses or by a nurse and a doctor. See example below.
The nurse in charge is responsible for arranging the assembly of a replacement pack as
described above in part 7.2.2
Name, Form of Preparation and Strength: Emergency Anaesthetic Drug Pack Tag No. 5532B
Expiry 05/2014 (shortest expiry in bag)
Date
Time
17/07/13
Patient’s Name
Amount Given
Ketamine10mg/ml (200mg/20ml) vial
BN: XYZ EXP: 07/2014
Midazolam 1mg/ml (5mg/5ml) ampoule
BN: LMN EXP: 05/2014
Fentanyl 50 microgram/ml (100micrograms/2ml) ampoule
BN: RPQ EXP: 03/2015
Assembled by:
EADP Bag Seal checked and Correct
18/07/13
21:00
19/07/13
14:15
Sam Jones 6759081
14:15
Sam Jones 6759081
Ketamine 20mg(2ml) given,
18ml discarded.
Midazolam 5mg given
Given By
(Signature)
Witnessed
By
(Signature)
Stock
Balance
MJones
JSmith
1
MJones
JSmith
1
MJones
JSmith
1
MJones
JSmith
LBrown
THarvey
JSmith
LBrown
0
JSmith
LBrown
0
Page 1
Start entry for re-assembly of bag on the next page
Name, Form of Preparation and Strength:
Emergency Anaesthetic Drug Pack. Tag No. 5533B Expiry 06/2014 (shortest expiry in bag)
19/07/13
15:00
Ketamine10mg/ml (200mg/20ml) vial BN: MML EXP: 08/2014
FGrey
HMoore
1
Midazolam 1mg/ml (5mg/5ml) ampoule BN:GFH EXP: 06/2014
FGrey
HMoore
1
Fentanyl 50 microgram/ml (100micrograms/2ml) ampoule BN: RPQ
EXP: 03/2015
Assembled by:
FGrey
HMoore
1
FGrey
HMoore
1
Page 2
Page 5 of 7
9. Implementation
This SOP will be made available to the Emergency Department and Critical Care staff
who must familiarise themselves with the procedure and ensure that they know their
responsibilities.
This SOP will also be made accessible on the intranet.
10. Process for Monitoring Compliance/Effectiveness
The ward manager will monitor the EADP register to ensure that daily checks are being
completed and the ward pharmacist will check both the CD and EADP registers every
three months to ensure that the appropriate documentation is in place.
11. Arrangements for Review of the SOP
This SOP should be reviewed in 3 years time or earlier if there are any significant
changes to the contents of the EADP or to the trust medication policy.
12. References
Southampton PICU Retrieval Drugs: Procedure for Controlled Drugs. May 2009
Wessex Major Trauma Network. Children’s Major Trauma Guidelines University Hospital
Southampton. 2012
Page 6 of 7
Appendix 1
Contents of the Emergency Anaesthetic Controlled Drug Pack
Aide memoire for inclusion on the outside of the drug pack
Emergency Anaesthetic Controlled Drug Pack
Drug
Ketamine
Midazolam
Fentanyl
Strength
10mg/ml
1mg/ml
50 micrograms/ml
Pack Size
200mg/20ml vial
5mg/5ml ampoule
100micrograms/2ml ampoule
Quantity
1
1
1
Page 7 of 7