MEDICINES POLICY
Document Summary
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Define the key aspects of safe & effective use of medicines including
prescribing, supply and administration
Define the Trust-approved practices relating to the safe & secure handling
of medicines
Minimise and control the risks to patients, the staff and the organisation
associated with medicines
DOCUMENT NUMBER
Version 4 (Final)
APPROVING COMMITTEE
Clinical Effectiveness Council
DATE APPROVED
July 2015
DATE IMPLEMENTED
July 2015
NEXT REVIEW DATE
June 2018
ACCOUNTABLE DIRECTOR
Medical Director
POLICY AUTHOR
Head of Pharmacy
TARGET AUDENCE
All staff who have involvement with handling or use of
medicines
KEY WORDS
Access the Medicines Resources Intranet site for
information, policies, procedures & guidance on medicines
including prescribing, the Formulary, administration,
controlled drugs, storage, adverse drug reactions
Click Here
Important Notes:
This Policy is designed for optimal use as an electronic document. It contains
bookmarks and hyperlinks which will not function if the Policy is printed.
The Intranet version of this document is the only version that is maintained.
Any printed copies should therefore be viewed as “uncontrolled” and, as such, may not necessarily contain the
latest updates and amendment
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Medicines Policy (June 2015)
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CONTENTS
This Policy is designed to be used in electronic rather than print format
To aid the location of commonly asked questions, specific policy subsections have been
bookmarked and listed in the contents section.
If the topic you are looking for is not listed in the contents tables:
 either go to the most relevant topic heading you and read the section
 Simultaneously press the ‘Ctrl’ and ‘F’ keys on your keyboard to display a FIND
dialogue box. Enter the term you are interested in and click NEXT. This will highlight
each reference to the search term throughout the document
 Ask a pharmacist or call Pharmacy Medicines Information on ext 1565
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Subject
(click hyperlinks to go directly to the section or contents sub-table)
Scope
Introduction
Statement of intent
Definitions
Duties, accountabilities and responsibilities
Medicines Optimisation Strategy
Committees – Area Prescribing Committee, Drug & Therapeutics
Group, Medicines Safety Group
Electronic prescribing & medicines administration system (ePMA)
Information sources on medicines (including patient information)
Prescribing
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NICE technology appraisals and clinical guidelines
Medicines Formulary
Individual funding requests
Antimicrobials
Outpatient antimicrobial therapy (OPAT)
Unlicensed medicines
Clinical trial medicines
Non-medical prescribing
Transcribing
Patient group directions (PGDs)
Drug history taking and medicines reconciliation on admission
Accuracy checking of prescriptions
Procurement, Supply and Dispensing
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Homecare delivery of medicines
Patients own drugs (PODs)
Storage of Medicines
Administration of Medicines
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Miscellaneous
 Drug Incidents
 Drug Defect Reporting Procedure
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Appendix 1
 Adverse Drug Reaction Reporting
 Suspected Theft or Fraudulent Procurement of Medicines
 Liquid nitrogen
 Disposal of unneeded and expired medicines and waste
 Leeches and maggots
 Medical gases
 Medicines-related policies, procedures and guidelines
Implementation of the Medicines Policy
Training
Monitoring compliance
Counter Fraud Statement also LSMS
References and bibliography
Policy history
Equality Analysis
Appendicies
Self Medication Policy
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Contents sub-tables
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Prescribing of Medicines
Drug history taking and medicines reconciliation
General principles of prescribing
Medicines optimisation & understanding patient experience
Patient details & addressographs
Age & Weight
Names of medicines
Doses & units
Routes
Frequency
Abbreviations
Blister packs
Inpatient prescribing
Signatures & prescriber identity
Multiple kardexes per patient
Allergies, sensitivities & warning information
When required (prn) prescribing
Administration times
Discontinuations
Alterations
Rewriting kardexes
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Verbal prescriptions in emergencies
Discharge prescribing (TTOs)
Outpatient prescribing
FP10(HP) prescriptions
Controlled Drugs (CDs)
Cytotoxic chemotherapy & cytotoxics used for non-cancer indications
Prescribing by staff for themselves, their families, those with
whom they have close relationships, signed orders
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Purchasing medicines for professional use
Private prescriptions
Non-medical Prescribing
Transcribing of prescriptions by 5th year medical students, pharmacy
and other staff
Patient Group Directions (PGDs)
Use of unlicensed medicines and use of medicines
for unlicensed indications
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Procurement and Supply of Medicines
Purchasing
Procurement contracts
Quality of purchased medicines
Quality of unlicensed medicines
Free samples of medicines
Supply of controlled drugs (CDs)
Supply of cytotoxic chemotherapy
Supply of medicines for inpatients
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Non-stock medication
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Dispensing for discharge
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Ward/Dept medicines stocks
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Medicines optimisation & patient experience
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Returning medicines
Dispensing discharge prescriptions (TTOs)
Delivery of drugs, receipt of deliveries and collection
from Pharmacy
Dispensing outpatients prescriptions
Containers
Emergency cardiac arrest boxes
 Medicines required urgently and in emergencies
Over the counter medicines
Aseptic Dispensing Unit
Blister packs
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Administration of Medicines
General principles of administration of prescribed medicines
Medicines optimisation and patient experience
 Non written prescriptions
 Emergency situations
 Verbal prescriptions By telephone
 Patient Group Directions (PGDs)
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 Homely remedies
Use of patients own medicines
Self-administration of medicines
 Supervised self administration
 Security of self-administered medicines
 Rescue medicines
 Symptom relief medicines (low risk)
 Independent self-administration
 Non-approved self-administration
Covert administration of medicines
Administration of cytotoxic chemotherapy
Supply of discharge prescription medicines (TTOs) to patients on
wards
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1. SCOPE
Aims of the policy
The aims of the Medicines Policy are to:
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Define the Trust-approved practices relating to the safe and secure handling of medicines
for all staff involved in the handling and use of medicines.
Minimise and control the risks to patients, the staff and the organisation associated with
medicines
Provide a auditable standards for medicines optimisation
Policy description
This Policy provides information and guidance to staff involved with prescribing, supplying
and administering medicines.
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2. INTRODUCTION
All Trusts are required to have a Medicines Policy to ensure the safe and secure handling
of medicines.
The Policy should be read by all individuals who are involved with medicines within the
Trust. The scope of the Policy is very broad, including most aspects of medicines handling
eg. prescribing, ordering, supply, transport, storage, administration. The Policy may be
used during the induction of new staff and also as a general reference source. It should be
used in conjunction with other relevant Trust policies, procedures and guidance eg.
Medicines Formulary, Emergency Prescribing Guide, Noddy’s Guide (Paediatrics),
Antibiotics Policy, ‘Clinical policies, procedures, protocols and guidance’.
Access to the Medicines Policy and other key references, procedures and guidelines
relating to medicines within the Trust is recommended via the Medicines Resources Intranet
site. This is accessible from the Home page of the Trust intranet by clicking the STHK
MEDS logo.
click to access the Medicines Resources Intranet Site
Key documents underpinning this Policy include legal and professional references:
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The Medicines Act 1968 and subsequent amendments
The Misuse of Drugs Act 1971 and subsequent amendments
The Safe and Secure Handling of Medicines – A Team Approach (RPSGB 2005)
Good practice in prescribing medicines – guidance for doctors (GMC 2013)
Standards for Medicines Management (NMC 2010)
Medicines, ethics and practice – a guide for pharmacists (RPSGB 2014)
British National Formulary (RPSGB & BMA Sept 2014)
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BNF for Children 2014-15 (RPSGB, BMA, RCPCH)
The Best Medicine: The Management of Medicines in Acute and Specialist Trusts (HCC
2007)
NICE National Guideline – Medicines Optimisation (NICE March 2015)
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3. STATEMENT OF INTENT
The safe, secure and cost-effective management of medicines within the Trust in
accordance with legal, professional, regulatory and advisory standards.
Relevant processes are defined and guidance is provided for key topics including:
 Prescribing
 Checking the accuracy of prescriptions
 Supply of medicines
 Administration of medicines
 Patient self-administration
 Storage and security of medicines
 Adverse drug reactions
 Disposal of unneeded medicines
 Monitoring compliance with the above
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4. DEFINITIONS
Abbreviations are clarified within the body of the document. The following are commonly
used terms:
Drugs - Prescribed medicines
Kardex - Inpatient prescription chart
NMP – Non-medical prescriber
PODs - Patients’ own drugs
Prescribing - To authorise, by means of a prescription, the supply or administration of a
medicine to a named patient.
Registered Practitioner - When used alone, refers to registered nurses, midwives and
operating department practitioners
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5. DUTIES, ACCOUNTABILITIES AND RESPONSIBILITIES
Chief Executive
The Chief Executive has overall responsibility for the strategic and operational management
of the Trust including and ensuring that the Trust complies with all legal, statutory and good
practice requirements
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Medical Director
The Medical Director is accountable to the Trust Board for providing assurance of
compliance with this Policy in all parts of the Trust and ensuring that the Policy is reviewed
and updated by the specified review dates.
Head of Pharmacy
The Head of Pharmacy has delegated responsibility for reviewing and revising this Policy.
He/she has responsibility for ensuring operational implementation and associated
monitoring of compliance with the Policy.
Chairperson of the Drugs and Therapeutics Group (DTG)
The DTC is the approving committee for the Medicines Policy. The Chairperson must
complete and sign the checklist for the review and approval of policy documents when the
committee agrees. The chairperson must ensure the minutes accurately reflect discussion
and approval of the Policy.
Chairperson of the Medicines Safety Group (MSG)
The MSG functions in parallel to the DTG and promotes the reduction of risk associated
with medicines, including storage, security and drug administration. The Chairperson and
supporting staff will ensure effective working in partnership with the DTG.
Director Nursing, Midwifery and Governance
Responsibility to ensure that nursing and midwifery staff are aware of and comply with the
relevant sections of the Medicines Policy.
Divisional and Clinical Directors
Responsibility to ensure medical staff that they line manage comply with the Medicines
Policy within their directorates.
Directors, Assistant Directors of Operations, Directorate Managers, Department
Heads
Responsibility for ensuring staff they line manage comply with the Medicines Policy
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6. MEDICINES OPTIMISATION STRATEGY
The Trust’s Medicines Optimisation Strategy 2014-18 provides medicines-specific aims and
objectives which support the Trust’s aims & objectives, the Trust Clinical & Quality Strategy,
the Nursing & Midwifery Strategy and other requirements eg. NICE, CQC, NHSLA, TDA etc.
This Strategy can be accessed on the Medicines Resources Intranet site via this link
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7. COMMITTEES – DRUG & THERAPEUTICS GROUP AND MEDICINES SAFETY GROUP
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Within the Trust there are two multidisciplinary, specialist groups with responsibility for
medicines:
Drug & Therapeutics Group (DTG, formerly called Drug & Therapeutics Committee DTC)
Medicines Safety Group (MSG)
The roles of the DTG include management of the Joint Medicines Formulary,
consultation/review/approval of Pan-Mersey APC recommendations, antibiotics, medicinesrelated guidelines & policies, PGDs, drugs expenditure. The DTG reports to the Clinical
Effectiveness Council.
The roles of the MSG include review of medicines incidents, drug safety & security,
medicines administration, controlled drugs, medicines safety initiatives. The MSG reports
to the Patient Safety Council.
Both Groups may be contacted via the Head of Pharmacy.
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8. ELECTRONIC PRESCRIBING & MEDICINES ADMINISTRATION SYSTEM (ePMA)
The Trust will commence implementation of the JAC ePMA, electronic prescribing and
medicines administration system during 2015. This will be rolled out across the Trust in an
incremental manner and is intended to eventually manage the majority of medicines
prescribing and administration within the Trust. The implementation of the system is being
managed by the multidisciplinary, clinically-led ePMA Project Board. The Chair of the
Project Board is a member of consultant medical staff nominated by the Medical Director.
Instruction provided in the Medicines Policy regarding prescription documents, handwriting,
abbreviations, signatures etc will not apply within the ePMA environment. However, the
principles of prescribing, supply and administration of medicines described in this Policy will
remain relevant and applicable even though the appearance of the prescriptions will
change.
All medicines-related policies, procedures, guidelines etc with content regarding current
paper-based prescription documentation will be reviewed and updated in due course. In
the interim, prior to update, clinical staff are authorised to apply the requirements of legacy
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policies to the equivalent actions within the ePMA environment eg. record administration of
a drug in the electronic record rather than the old, card inpatient kardex.
During roll-out and development of the system capability, certain prescribing and
administration functions may not be possible within the ePMA environment eg. oxygen, and
complex intravenous infusions. In such cases, the medicine must still be prescribed on
ePMA but in the dose instructions it will specify that the details for dose administration are
as prescribed on a specialist card prescription sheet.
As with other clinical record and clinical informatics systems, adherence to Trust
Information Governance requirements including security, confidentiality and accuracy is
mandatory for all staff using the ePMA system.
Management of the ePMA system will be conducted by authorised staff from Health
Informatics and Pharmacy.
Existing Trust working groups with an interest in medicines will review and approve
changes to the ePMA system relating to the clinical use of drugs. This will include the Drug
& Therapeutics Group and the Medicines Safety Group.
There will be a systematic approach to developing decision support within ePMA, reducing
risks by applying lessons learned from incidents and feedback.
A balance will be maintained between interaction with system users through pop-up
messages, mandatory fields and usability.
Wherever suitable, the most common doses, routes and frequencies will be pre-filled for
drugs within the ePMA database.
Tall man lettering and the National dm+d drugs dictionary will be used wherever possible
when setting up drug files.
The ePMA software and supporting hardware is designed to support prescribing & drug
administration within the clinical environment. Medicines administration to inpatients on
wards will be recorded on ePMA using computers on medicines trollies in a similar manner
to the historical use of inpatient kardexes.
A medicine may only be recorded as administered on ePMA after it has been administered
to a patient, NOT before.
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9. INFORMATION SOURCES ON MEDICINES (including patient information)
Good quality, up to date information is essential for the safe and cost-effective use of
medicines. Increasingly, major reference sources are being published electronically and
the circulation of paper, hard-copy editions is being reduced. It is essential that out-of-date
information is not used for the care of patients. The web versions of major reference
sources are updated continuously whereas print copies may only be updated less often. As
a result, it is becoming preferable to use the web reference sources.
Within the Trust, the Medicines Resources intranet site has been created to provide easy
access to key information about medicines. The site includes readily accessible links to the
web versions of key reference sources on medicines such as the BNF, BNF-C, Electronic
Medicines Compendium and Medusa. The intranet site also includes extensive links to
policies, procedures, guidelines, local & national guidance, the Pan Mersey Formulary,
professional standards, patient information etc.
Click this link to access the Medicines Resources intranet site
Increasingly, key reference sources are available as apps for smartphones and tablets.
These can be highly useful. Caution is advised to users of apps to ensure that they are
high quality and up to date. The following apps are recommended:
BNF
BNF-C
eMC
Mersey Micro
British National Formulary
BNF for Children
Electronic medicines compendium – contains manufacturers’ summaries
of product characteristics for most UK-licensed medicines. Also contains
patient information leaflets and other information such as videos on use of
devices eg. inhalers
St Helens & Knowsley Teaching Hospital’s award winning, MHRA CEapproved app for our Trust antibiotics guidelines
Within the new electronic prescribing system (ePMA) decision support information is
provided by First Data Bank (FDB). FDB is an international leader in medicines information
and their electronic databases are extensively used with many electronic clinical systems
both in primary and secondary care.
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Other sources of information include advice from peers, senior clinical staff, ward
pharmacy staff, on-call pharmacists
Pharmacy provides a Medicines Information helpline within the Trust. This is available
on ext 1565 or 0151 430 1565 (direct line)
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10. PRESCRIBING OF MEDICINES
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General principles
Inpatient prescribing
Discharge prescribing
Outpatient prescribing
GENERAL PRINCIPLES OF PRESCRIBING
All medicines intended to be administered to a patient under the care of the Trust must be
prescribed by an authorised prescriber on an official Trust prescription document, except in
strictly defined circumstances eg. under the terms of a PGD, midwives.
The GMC guidance document – ‘Good practice in prescribing and managing medicines and
devices’ underpins prescribing practice and the Trust supports prescribing in accordance
with these principles.
Should anyone be found to have prescribed drugs without authority then this may be
construed as Fraud and the matter should be referred to the Trust’s Local Counter
Fraud Specialist to investigate.
Medicines optimisation – understanding the patient’s experience
Up to 50% of patients do not take their medicines as recommended. To ensure the best
possible outcome from medicines, there must be an ongoing, open dialogue with the patient
and/or their carer(s) about the patient’s choice and experience of using medicines to
manage their condition. It must be recognised that a patient’s experience may change over
time even if their medicines do not.
The prescribing process
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Decision is made to prescribe a medicine for the treatment of a patient by an authorised
prescriber
Only official Trust prescription documentation can be used (paper or electronic)
If completing the prescription in handwriting, use indelible black ink and write clearly
Include the patient’s name, address, hospital or NHS number on the prescription (or
use and addressograph label). Include other details such as date of birth and weight
when required
Specify the location/cost centre from which the patient is being treated eg. ward
number, clinic speciality
Specify the name of the consultant responsible for the patient’s care
Specify the drug name, dose, route and frequency for each medicine prescribed.
Include duration and other details as relevant.
The prescriber must sign, print their name & contact details and date the prescription
(or authorise electronically for e-prescriptions)
Definition of prescribing - to authorise, by means of a prescription, the supply or
administration of a medicine to a named patient.
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Official Trust Prescription Documents – these include inpatient prescription
kardexes/charts, outpatient prescriptions, discharge prescriptions (TTOs), anaesthetics
record sheets, ICU & HDU Drug Prescription Chart. The Trust Drug and Therapeutics
Group must be consulted about proposed changes to prescription documents. A selection
of the most commonly used Trust prescription types may be viewed via this link.
The clarity of a prescribing instruction is the legal and professional responsibility of
the prescriber. The prescription must be legible and it must not be open to
variability in interpretation. The Trust considers that failure to prescribe clearly is a
matter of professional misconduct.
Patient details & addressographs. Addressograph labels must be placed on all
prescription sheets. These give full identification details for patients and also a bar code.
These details should only be handwritten in exceptional circumstances when
addressographs are not available. If the details are handwritten, the patient’s name must
be written in full.
Patient’s age and weight. These details are necessary on prescriptions for children and
also for many adults.
Consultant and cost centre details. Details of the consultant, ward/clinic/dept must be
written on all prescriptions.
Name of the medicine must be written clearly in indelible ink using approved names when
possible. Proprietary names (ie. brand names) must not routinely be used. Exceptions
include multi-ingredient preparations with no approved names or products whose
proprietary names define a specific formulation (eg. slow–release theophylline and
morphine preparations). Patients with sensitivities to particular excipients may benefit from
proprietary names being specified.
Doses and units.
 The dose must be prescribed using S.I. units using weights whenever possible. Decimal
points should be avoided, for example 500mg should be prescribed instead of 0.5g. If a
decimal point is unavoidable eg. for digoxin doses, great care must be taken by both the
prescriber and the nurse administering the drug. The terms microgram and nanogram
must not be abbreviated but must be written in full and used for quantities less than one
milligram. Only approved abbreviations are acceptable.
 When the dose of a drug is expressed in units eg. insulin and heparin, the term ‘units’
must be written in full and not abbreviated.
 The dose required should not be expressed in terms of the number of
tablets/capsules/spoonfuls. For example “Atenolol 2 tablets” is unclear as there are 3
strengths of tablets. It should be written as “Atenolol 100mg tablets”
 Drugs which are to be administered via the intravenous route should state the doses
and the diluent to be used including the amount. Details of the duration of
administration should also be specified. eg. clarithromycin 500mg diluted in 250ml of
0.9% sodium chloride and infused over 1 hour. The Electronic Medicines Compendium
or the Medusa database provides this information.
 It is not practical to prescribe some medicines by specific weight or volume eg. creams,
eye drops. In such cases the prescriber should be as specific as possible about the
dose eg. instil 2 drops, apply sparingly to the hands.
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Routes of administration
Routes must be clearly indicated to avoid misinterpretation of the intentions of the
prescriber. Only the approved abbreviations are acceptable.
Frequency of administration
Frequency must be clearly indicated to ensure that doses are administered at the correct
times. Only approved abbreviations for frequency may be used
Abbreviations
Drug names – Do not use abbreviations for drug names as this increases the risk of error.
eg. ISMN, KCl, NaCl. The only exception is the use of GTN as an abbreviation for glyceryl
trinitrate.
Dose abbreviations. The following abbreviations are acceptable
QUANTITY
milligram
gram
kilogram
litre
millilitre
millimole
APPROVED
ABBREVIATION
mg
g
kg
L
ml
mmol
Route abbreviations. The following abbreviations are acceptable
ROUTE
APPROVED ABBREVIATION
Intramuscular
Inhalation
Intravenous
Nasogastric
Nebulised
Percutaneous Endoscopic
Gastrostomy
Oral
Rectal
Subcutaneous
Sublingual
Topical
Vaginal
IM
INH
IV
NG
NEB
PEG
PO
PR
SC
SL
TOP
PV
ALL OTHER ROUTES MUST BE WRITTEN IN FULL
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Frequency abbreviations and other instructions. The following abbreviations are
considered acceptable when writing discharge or outpatient prescriptions
Abbreviation
Meaning of Abbreviation
ac
bd
e/c
hs
mane
nocte
od
om
on
prn
Pc
qds
q8h
qqh
sos
STAT
tds
tid
Before food
Twice daily
Enteric coated
At bedtime
In the morning
At night
Daily
In the morning
At night
When required
After food
Four times daily
Every 8 hours
Every four hours
When necessary
One-off dose
Three times a day
Three times a day
Child resistant containers (CRCs) eg. clic-lock caps are used routinely on discharge and
out patient prescriptions. If CRCs would be difficult for the patient to open, then plain tops
will be provided if the prescriber writes NO CRC on the prescription. If this is not specified
by the prescriber, but clinical staff (eg. nurse, pharmacist) judge that CRCs are
inappropriate, the prescription should be endorsed and signed to indicate that CRCs are not
required.
Documentation in medical records. Details of new medicines, discontinued medicines
and changes to existing treatments should be documented in the patient’s medical records.
It is good clinical practice to document the rationale eg. indication for treatment,
discontinued due to side effects etc. The intended plan of treatment should be indicated
eg. duration, review, monitoring etc.
Blister packs. If compliance is thought to be a problem the Pharmacy will, if appropriate,
provide blister packs.
The Pan Mersey Local Professional Network for Pharmacy has issued a guidance
document to support appropriate use of blister packs. This emphasises the importance of a
holistic approach to patient management when blister packs are being considered including
handover and continuation of use in primary care. There are many blister pack systems
available and unless a community pharmacy provider continues care using the same
devices issued in hospital, this could lead to unintended patient confusion. This is
impractical and in many cases it may be better to arrange for the patient’s GP to arrange a
prescription for blister packs from the patient’s regular community pharmacy than to make
the supply from hospital. Click here to access the Pan Mersey Pharmacy LPN guidance
document on blister packs.
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The doctor should clearly annotate the prescription ‘BLISTER PACKS’. Not all drugs are
suitable for blister packing (speak to your ward pharmacy staff or Pharmacy Medicines
Information for advice).
For outpatients or patients being discharged, consideration must be given to the
continuation of the blister packing in primary care.
Because of the time taken to prepare dispense a prescription into blister packs, 24 hours
notice is required except in exceptional circumstances. The blister packing service is not
available at weekends.
The likelihood of children coming into contact with the medicines contained in a
blister pack should be considered and advice given.
Medicines Formulary. Prescribers must prescribe in adherence with the Trust’s Medicines
Formulary.
Click this link to go to the Policy section on the Formulary
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INPATIENT PRESCRIBING
The general principles for prescribing apply as described earlier in this Policy
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Drug history on admission and medicines reconciliation).
Click here to go to the section on medicines reconciliation on admission
Inpatient prescription documents include the inpatient prescription kardex,
anticoagulation prescription, anaesthetic chart, intensive care prescription, ChemoCare eprescriptions, JAC ePMA prescriptions.
The function of the inpatient prescription kardex (and other inpatient prescription
charts) is:
 To provide a permanent record of the patient's medication
 To indicate the patient’s medicine sensitivities/allergies
 To facilitate the supply of the correct medicines from Pharmacy
 To direct the administration of medicines to the patient
 To record the administration of medicines
A new inpatient prescription kardex (chart) must be written for each new admission of
an individual patient. It is not necessary to rewrite prescriptions for patients who have been
on short term leave from the ward eg. cytotoxic chemotherapy patients on weekend leave.
Patient details. The patient’s name (written in full), hospital number, date of birth, ward
and the name of the consultant must be entered on the front of each medicine kardex. An
addressograph label is recommended.
Weight should be accurately recorded in kilograms (kg) on the inpatient medicines kardex
and clinical record. For paediatric patients and those on drugs with weight dependant
doses, the weight must be entered.
Signatures & prescriber identity. All prescriptions must be signed (with name & contact
details printed in the section on the front of the kardex) by one of the following:
 A registered medical or dental practitioner
 Provisionally registered medical or dental practitioners carrying out prescribing activities
relating to their duties as foundation stage trainees
 A non-medical prescriber authorised to prescribe within the Trust
Click here to view a memo giving illustrated instruction on signatures and prescriber identity
Medical students employed as “locums” in the absence of FY1 foundation stage
doctors ARE NOT allowed to sign prescriptions.
Should anyone be found to have prescribed drugs without authority then this may be
construed as Fraud and the matter should be referred to the Trust’s Local Counter
Fraud Specialist to investigate.
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Multiple kardexes. When a patient requires more than one kardex, the number of
kardexes should be clearly stated on each kardex .
Allergies, sensitivities, intolerances and other important warning information
 Details of any allergies must be recorded in the designated section on the front of the
medicines kardex. If the patient has no known allergies then this must be indicated
using the approved abbreviation NKDA (no known drug allergies). This must also be
entered on subsequent prescription sheets. The absence of allergy documentation
leads to delays in the administration of medicines as clinical staff need confirm if it is
safe to administer them.
 Other factors relevant to the safe prescribing and administration of medicines such as
intolerances, insensitivities, renal or liver impairment, pregnancy, special diet or
disability eg. blindness should also be indicated on the kardex.
 If inappropriate or impractical to enter such details on the kardex, a note on the kardex
to direct other health professionals to details in the medical notes should be provided.
Date. The date upon which treatment is to commence must be written for each drug newly
prescribed. When a kardex is rewritten, the date that the drug was initially started should be
entered in the date section (not the date that the kardex was rewritten).
Validity. The prescription will be considered valid until cancelled by the prescriber, the
administration section is full or the patient has been discharged.
Duration. All prescriptions for antibiotics must have a review date or course duration
specified. Course duration for other relevant drugs should be also specified eg. ‘for 5 days’,
‘for 9 months’. This may be reinforced by crossing off the days on which treatment should
not be given in the administration section of the kardex. This Policy requirement is audited
for antibiotics and other drugs specified in CQUIN requirements and the Pan Mersey APC
Formulary recommendations eg. atorvastatin, clopidogrel, PPIs.
All current medicines need to be written on the prescription sheet, including details of
oxygen therapy, irrigations, parenteral nutrition and dressings supplied by Pharmacy, iv line
flushes all of which are prescription only medicines. Dieticians may add dietary
supplements to the prescription sheets. Cross-reference must be made on the prescription
chart to other drugs prescribed on separate charts eg. anticoagulants, cytotoxics and
dialysis fluids
When required (PRN) medicines. For prn medicines which can be administered by
multiple routes depending upon patient needs, it may be clearer to prescribe the drug once
on the kardex but to indicate the prescribed routes eg. O/IV. This is only appropriate when
the doses by each route are the same eg. metoclopramide. If the doses by each route are
different eg. prochlorperazine, each route required must be prescribed individually.
Guidance on the frequency of administration of prn medicines must be indicated and a
maximum dose in 24 hours specified if applicable eg. “metoclopramide 10mg PRN” is not
adequate. It should be “metoclopramide 10mg every 6 – 8 hours PRN, MAX 30mg in
24hours.”
Times of administration. For ‘regular medicines’ the prescribing times should be in
accordance with regular medication rounds wherever possible. Care should be taken to
space the doses evenly especially in the case of vancomycin and enoxaparin and modified
release opioid preparations. Consideration should also be given to the time of
administration and the timing of samples for therapeutic drug monitoring eg. warfarin,
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digoxin.
Discontinuing medicines
 The date of discontinuation must be entered into the “finishing date” box
 The entry must be initialled by the prescriber discontinuing the medicine
 A diagonal line should be drawn through the prescription so that its cancellation is
obvious, but the prescription should not be obliterated
 Incorrect entries must be scored through and the word ‘cancel’ written against them by
the prescriber and signed
 Medicines prescribed on separate charts eg. warfarin must be discontinued on both
documents
 Click here to view an illustrated guide to discontinuing medicines
Altering prescriptions
 If a prescription for a medicine requires alteration (eg. changed dose, frequency or
route) it should be discontinued as detailed above and rewritten.
 This is essential to maintain an accurate record of changes to a patient’s treatment and
also to prevent fraud.
Re-writing of Prescriptions
 CAUTION – the transcribing of information from one prescription sheet to another
is the most common cause of prescribing errors.
 Prescription sheets must be re-written when they become untidy especially after several
medications have been stopped and/or changed.
 When re-writing prescriptions, the prescriber must ensure that the dates entered relates
to the date when the therapy commenced and not the date of re-writing. It should be
indicated on the prescription that the treatment has been reviewed. The date of rewriting should be recorded on the top right hand corner of the front of the prescription
sheet.
Verbal prescriptions in emergencies and prescribing by telephone
In the interest of patient safety, prescriptions must not be given or accepted over the
telephone, except in an emergency (see section on non-written prescriptions).
Telephone orders will NOT be accepted by Pharmacy.
Process for ensuring the accuracy of all prescription charts
Click this link to go to the section on accuracy checking of prescriptions
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DISCHARGE PRESCRIBING (TTOs)
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The general principles for prescribing apply to discharge prescriptions written on the ICE
electronic discharge system (and also the hard-copy TTO form for areas authorised to use
this). When JAC ePMA electronic prescribing is rolled out, TTOs will be written using
ePMA.
The function of the discharge (TTO) prescription is primarily:
 To facilitate the supply of the correct medicines from Pharmacy
 To provide a record of medicines supplied on discharge for the medical notes
 To provide a list of current medicines treatment to the GP for the purpose of handover of
care and continuation of treatment
 Essential information should be communicated on the discharge prescription to facilitate
safe transfer of care. This is particularly important for medicines where this information
is required to ensure that future doses are safe, such as dose, weight, renal function,
indication and duration of treatment eg. prescriptions for enoxaparin, reducing courses
of steroids, warfarin, antibiotics, clopidogrel, proton-pump inhibitors, ticagrelor
TTO documents. All discharge prescriptions must be written on a Trust-approved
discharge prescription form. Whenever possible this will be through the ICE electronic
discharge system. The only exception at the time of writing this Policy is for Obstetrics who
write discharge communications using the Medway system.
TTO authorisation & signatures. TTO prescriptions may only be electronically submitted
(or signed & dated) by one of the following:
 A registered medical or dental practitioner
 Provisionally registered medical or dental practitioners carrying out prescribing activities
relating to their duties as house officers (FY1)
 Non-medical prescriber authorised to prescribe within the Trust
Medical Students. Medical students employed as “locums” in the absence of FY1
foundation stage doctors ARE NOT allowed to sign or authorise prescriptions
Date and time of discharge. The date and time of discharge should be specified on the
TTO. This is done automatically on ICE.
Multiple TTO sheets for individual patients. If more than one TTO sheet is required for a
patient eg. when on many medicines, the number of sheets should be indicated clearly on
each sheet eg. 1 of 2, 2 of 2 or on the appropriate section of the TTO.
Additional TTOs. If an additional TTO is submitted after the original TTO has been
authorised and dispensed, it is essential that the TTO is clearly endorsed ‘additional TTO’ to
advise pharmacy and nursing staff to ensure that all medicines are supplied when the
patient is discharged. If a controlled drug (CD) prescription on ICE, the CD must be
prescribed in full on ICE and also prescribed on a green CD TTO prescription. With ICE,
the ‘see CD prescription’ option in the Pharmacy Notes box should be selected.
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All medicines should be prescribed. The prescriber should prescribe every medication
that the patient is taking and not just those that need to be dispensed for discharge. Where
supplies are not required this should be indicated if known. Exception to this
recommendation is acceptable when a patient has been admitted for a very short stay eg.
over-night, GPAU, Acute Medical Unit. In such cases the TTO should document that there
have been no changes to the medicines on admission. If there are changes follow the
instructions in the next section below.
Changes to medicines during an admission. Details of any changed or discontinued
medicines should be provided on the discharge summary form if possible (this will be
prompted on the new electronic discharge system). The prescriber should be clear whether
a medicine is being stopped or withheld. If withheld, when it is to be restarted? Include any
instructions necessary (such as blood tests) for restarting the medicine eg. in patients with
Acute Kidney Injury
Advanced planning for TTO prescribing is essential to avoid discharge delays
 The multi-disciplinary team has a key role to play in discharge planning.
 Doctors are responsible for ensuring that TTO prescriptions are written giving Pharmacy
sufficient time to dispense and return them to the ward without delaying discharge. This
is particularly important for complex prescription requirements eg. blister packs.
 Prescriptions received in Pharmacy after 3.30pm may not be received back on wards
until after 6pm, leading to delayed discharge and inconvenience.
Process for accuracy checking of TTO prescriptions. Please refer to section 2.1 for
general requirements for accuracy checking.
 TTO prescriptions should be checked against inpatient kardexes by a pharmacist for any
transcribing errors before dispensing
 On wards where there is a regular ward pharmacist and/or pharmacy technician service
the TTO prescription should be retained on the ward until the ward pharmacist can check
it for correctness against the kardex. This avoids the need for the kardex to leave the
ward. Many wards have access to pharmacists and pharmacy technicians via a
designated bleep which can be used to inform them that a newly written TTO is ready for
checking.
 If TTOs are written after a scheduled pharmacist/technician visit or there is no scheduled
visit, the ward is required to send their TTOs to Pharmacy along with the corresponding
medicines kardexes. TTOs cannot be dispensed unless they are checked against the
kardex for correctness. Upon receipt in Pharmacy, a pharmacist will check the TTO
against the kardex and arrange for the kardex to be returned to the ward as soon as
possible via the Pharmacy porters.
Out of hours TTOs. Good planning can minimise the need for TTO dispensing during
evenings and weekends. This also ensures that the TTOs are thoroughly reviewed for
safety, quality and whether supplies need to be dispensed. Targeted TTO dispensing
service for urgent patients is available on weekend afternoons. This is co-ordinated by the
site manager/bed manager. Check with the ward, operational services or Pharmacy for
current Pharmacy service availability for TTO dispensing outside of normal hours.
A number of wards have the facility to use pre-labelled medicines to support out of hours
discharges. These include the Acute Medical Unit, Surgical Admissions Unit, Paediatrics,
Maternity Unit. Guidance is in place in these areas to support the safe use of this facility.
In an emergency, the on-call pharmacist can provide advice.
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Discharge prescription supply quantities
 Patients will receive a minimum of 14 days supply of regular medicines on discharge
(more will be given to cover public/bank holidays).
 For very short admissions eg. an overnight admission, if the patient has more than 7
days of their own regular drugs a further supply of these from Pharmacy will not usually
be made. However, in most cases Pharmacy will supply medicines in manufacturers’
original packs which usually contain 28 days’ supply of medicines.
 When suitable, Pharmacy may supply inpatients with original packs of non-stock
medicines, devices, topical medicines, calender packs etc fully labelled with instructions
for use. This is termed dispensing for discharge (or one-stop dispensing OSD). These
medicines can then stored in the locked cabinet by each patient’s bed.
 Dispensing for discharge is used in conjunction with utilisation of patients own drugs
(PODs) if these are available and suitable for use.
 When the decision to discharge the patient is made most, if not all, of their medicines will
be ready dispensed on the ward in a form suitable for patients to take home.
 With good organisation and planning, this minimises the delays inherent in dispensing all
of the TTO medicines on the day of discharge.
 Only 7 days will be supplied on discharge for monitored dosing systems such as blister
packs.
 A minimum of 14 days’ supply (when appropriate) will be supplied (except for very short
admissions as explained above) or for blister packs.
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OUTPATIENT PRESCRIBING
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The general principles for prescribing apply apply for outpatient prescriptions. When JAC
electronic prescribing (ePMA) is rolled out, outpatient prescribing will always be via eprescribing where possible.
The outpatient prescription enables the legal supply of medicines from the hospital
Pharmacy only. They cannot be dispensed by community pharmacists in primary care on
the NHS.
Is there a need to prescribe? Prescribers are asked to consider if it is always necessary
to prescribe for individual outpatients. They should not prescribe to replenish GPprescribed medicines which the patient is running short of. If a treatment is not urgent and
is for a non-specialist drug, consideration should be given to writing to the patient’s GP
requesting that they initiate the recommended treatment. This has the advantage of
reducing waiting times in the outpatients pharmacy and also reducing confusion for patients
(as community pharmacist dispensed medicines may differ considerably in appearance
from brands used in hospital). Recommended treatments must still comply with the
Formulary.
Outpatient prescription documents & prescription pad security. All prescriptions must
be on the Trust-approved outpatient prescription sheets or where appropriate the green
FP10 (HP) prescriptions. Both types of prescription are controlled stationary and may only
be ordered from Pharmacy by authorised staff. Collection of supplies of pads must be
signed for. Stocks of prescription pads within clinical areas must be stored securely. In-use
pads must be managed securely and always locked away when not in use.
Prescribers authorised to sign outpatient prescriptions. Only the following staff can
sign outpatient prescriptions:
 Registered medical or dental practitioner
 A non-medical prescriber authorised to prescribe within the Trust
Pre-registration FY1 foundation stage doctors and medical students employed as
“locums” in the absence of FY1s ARE NOT allowed to sign outpatient prescriptions
Quantities of supply. 28 days supply will be dispensed unless circumstances dictate that
a different supply is necessary. This includes:
 Antibiotics - 7 days unless otherwise specified
 Short term analgesics - original packs
 A&E prescriptions - 7 days unless otherwise specified
 Hospital only medicines – these cannot be prescribed by General Practitioners
 Clinical Trial medicines
 Pulsed/cyclical treatment
 Antidepressants prescribed by consultant psychiatrists to ensure continuity of treatment
 Reducing/ increasing doses of drugs e.g. steroids
 Drugs for tuberculosis treatment
 Haematology treatment
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


Drugs with shared care agreements (e.g. donepezil, riluzole)
Drugs to ensure continuous supply over public/bank holiday
Anticoagulants
Process for ensuring the accuracy of outpatient prescriptions
Please refer here for details regarding accuracy checking
FP10(HP) prescriptions
a)
b)
c)
d)
e)
f)
g)
h)
A restricted number of clinics/prescribers are provided with FP10 (HP) prescription
pads. These are normally for use ‘out of hours’ or for outreach clinics to allow
patients to obtain medicines from community pharmacists, where it would be of great
inconvenience to the patient insist on supply from the hospital pharmacy.
FP10 (HP) prescription forms are only to be used for registered out-patients to take
to outside pharmacies. Green FP10(HP) must not be used to order food or toilet
articles and other prescriptions which are not drugs or appliances other than those
specified in the drug tariff
Pre-registration FY1 House Officers ARE NOT allowed to sign FP10 (HP)
prescriptions
FP10 (HP) must not be used to prescribe for in-patients, private patients, by hospital
staff for themselves or their families/colleagues unless specific approval has been
given by the Head of Pharmacy usually in combination with service managers and a
Trust Executive.
FP10 (HP) must not be used for prescribing outside of the Formulary guidance.
Medicines prescribed on FP10(HP) often cost the Trust far more than when
dispensed by the Trust Pharmacy Dept.
Poorly written or incomplete FP10(HP) prescriptions can cause great difficulty and
inconvenience for patients and community pharmacists.
Data relating to medicines prescribed using these forms are collated by the
Prescription Pricing Bureau in electronic format, including prescriber details and the
drugs prescribed. This information is audited regularly.
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PRESCRIBING CONTROLLED DRUGS
Click here to access the Trust Policy for the Management of Controlled Drugs. (Prescribing
is covered in Chapter 5, pages 9-12).
Methadone must NOT be prescribed for discharge where an addict has a registered pick-up
point. If it is not possible to make arrangements the minimum possible quantity should be
provided and an absolute maximum of 2 days prescribed for addicts.
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PRESCRIBING CYTOTOXIC CHEMOTHERAPY (INCLUDING METHOTREXATE FOR
NON-CANCER INDICATIONS)

Unless you are trained, authorised and registered within the Trust to prescribe
intrathecal chemotherapy, you MUST NOT prescribe or administer these treatments.

Separate polices are available for vinca alkaloids, oral anti-cancer medicines and
intrathecal chemotherapy. Click here to go to the Medicines Resources Intranet site to
access these

The Trust follows Merseyside and Cheshire Cancer Network policies, guidelines and
protocols for chemotherapy prescribing in cancer. Detailed information is available of
the MCCN website.

Cancer chemotherapy within the Trust will be prescribed using the ChemoCare
electronic prescribing systems wherever possible. The strategy is for all chemotherapy
prescribing to be via ChemoCare when all of the necessary protocols are uploaded.

Particular care is needed when a patient is treated with potent cytotoxic
chemotherapeutic agents.

Records of the prescribing and administration of chemotherapy should be organised and
clear so that the overall plan of treatment given is intended and clear.

Regimes must be prescribed on the basis of a protocol whenever possible. The first
course must be prescribed by a Consultant, Senior Registrar, Staff Grade or Associate
Specialist with appropriate training and experience

Methotrexate. Methotrexate is commonly prescribed for non-cancer indications. These
indications will usually be restricted to rheumatoid arthritis and psoriasis for which they
are usually initiated by specialists. Patients may admitted to hospital for other conditions
whilst on methotrexate. Prescribers should note that methotrexate is prescribed as a
WEEKLY dose on a specified day per week. Methotrexate must NEVER be
prescribed daily for non-cancer indications. To avoid misinterpretation and
accidental daily administration prescribers must specify the day of administration and
cross off the days in the administration section of the kardex when patients are not to
receive methotrexate. Methotrexate must not be prescribed in any circumstance with
the dose, frequency or route specified ‘as directed’. Specific procedures are in place for
managing oral methotrexate. These can be obtained from Pharmacy Medicines
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Information or via this link on the intranet. Pharmacy will only supply 2.5mg strength
tablets of methotrexate when tablets are prescribed in line with Pan Mersey locality
policy.
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PRESCRIBING BY STAFF FOR THEMSELVES, THEIR FAMILIES, CLOSE
COLLEAGUES, ORDERS FOR PERSONAL SUPPLIES AND DUTIES OUTSIDE OF THE
TRUST

Medical staff and non-medical prescribers must not prescribe for themselves, their
families or anybody with whom they have a close personal relationship in line with the
current GMC guidelines http://www.gmc-uk.org/guidance/ethical_guidance/14318.asp.
Advice must be sought from the Head of Pharmacy or Medical Director BEFORE
prescribing in these scenarios if an exception is believed appropriate. Concerns
regarding attempts to inappropriately prescribe will be passed to the Medical Director.
Such instances may also result referral to the Local Counter Fraud Specialist (LCFS) for
investigation.

In emergencies, medical staff should attend existing facilities in outpatients, the Accident
& Emergency Department or Occupational Health, where a senior doctor will prescribe
as necessary. The current prescription charge will be payable.

FP10 (HP) prescription forms must never be used by medical staff to prescribe for
themselves or their families. This may be classed as Fraud and such matters should be
referred to the Trust Local Counter Fraud Specialist to investigate.
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PURCHASE OF MEDICINES FOR PROFESSIONAL USE
Due to changes in the interpretion of European law, the MHRA has advised during 2014
that only MHRA-licensed medicines wholesalers may supply stock of medicines to other
organisations or individuals.
Therefore Pharmacy can no longer make sales via signed orders to consultant medical staff
for use within their private practice
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PRIVATE PRESCRIPTIONS
Private prescriptions will not be dispensed by Pharmacy unless by specific arrangement
with the Head of Pharmacy or Deputy. The only appropriate circumstances foreseen at the
time of writing this Policy would be to support Trust-run private clinics or other clinical
activity. Pharmacy will not dispense private prescriptions for patients, the public or
members of staff and their families unless in the course of official Trust activity.
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11. NICE TECHNOLOGY APPRAISALS AND CLINICAL GUIDELINES
The National Institute of Clinical Effectiveness (NICE) has published many technology
appraisals (TAs) and clinical guidelines (CGs) relating directly to medicines or including
medicines as elements of treatment within them.
There is a National requirement for NICE TAs for medicines to be implemented within 3
months of publication. This also requires update of the Trust’s Medicines Formulary and
publication within the 3 month time period.
The Trust’s Drug & Therapeutics Group works closely with the Pan-Mersey Area
Prescribing Committee to ensure that the Joint Medicines Formulary is updated within 3
months. The policy and procedures for the Area Prescribing Committee provide details of
the approach and processes involved to achieve this.
All Trust prescribing must be consistent with relevant NICE requirements (and timescales)
unless there are specific reasons why this is not appropriate. For individual patients this
may include situations where NICE-recommended treatments are contra-indicated.
The management of NICE implementation within the Trust is covered within the Trust Policy
for Implementation of NICE Guidelines. Click here to access this Policy.
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12. MEDICINES FORMULARY
Prescribers should only initiate prescriptions for medicines which have been approved by
the Trust Drug and Therapeutics Group (DTG) for use within the Trust. Medicines have
been selected for inclusion in the Medicines Formulary taking consideration of costeffectiveness, safety and relevant guidelines (eg. NICE Technology Appraisals).
The approved drugs are listed in the Pan Mersey Area Prescribing Committee Joint
Medicines Formulary (click here to access the Formulary)
Click the icon to access the Formulary
The Formulary cannot accommodate every possible prescribing scenario and individual
patient need. Therefore exceptions can be made when individual patient circumstances
justify eg. allergy, side effects, failure to respond to formulary-listed drugs.
It is acceptable for prescribers to continue prescriptions for non-Formulary drugs which
have been initiated by another prescriber (eg. a GP, tertiary care consultant) for individual
patients whose condition does not justify changing their prescription. This is commonly the
case for elective patients admitted for surgical procedures.
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If a patient is admitted already on a non-formulary drug we will normally continue their
treatment using their own supply of this drug. If further supplies are required, the minimum
to provide for this patient’s needs will be ordered by Pharmacy.
Prescribers who wish to request that a new drug be added to the Formulary, or for other
amendments to be made should correspond with the DTG via the Head of Pharmacy or the
Chairman of the DTG. The Trust’s DTG collaborates with other Trusts and CCGs within the
Pan Mersey locality. The process for changes to the Formulary requires approval by the
Pan Mersey Area Prescribing Committee.
High cost non-Formulary drugs required for isolated treatment of an individual patient will be
subject to an individual patient commissioning process (often referred to as individual
funding requests or IFRs).
Audit systems are in place both within the hospital and in primary care to monitor Formulary
compliance. This includes the recommendation of non-Formulary drugs by referral to GPs
by letter. Compliance by Trust prescribers with the local Formulary is included as a
performance measure within the Trust’s Quality Contract with local commissioners.
Click this link to go to the Pan Mersey Area Prescribing Committee website
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13. INDIVIDUAL FUNDING REQUESTS (IFR)
Application for funding of exceptional cases should be made via an IFR. Such applications
must comply with both of the following requirements:
 The patient is significantly different to the general population of patients with the
condition in question
 the patient is likely to gain significantly more benefit from intervention than might
normally be expected for patients with that condition.
IFR applications must be approved by the Chair of the Drug and Therapeutics Group or
Head of Pharmacy before submission, completed forms should be sent to
mike.welsby@sthk.nhs.uk.
The full requirements and application form may be found on the Pan Mersey Area
Prescribing Committee website http://www.panmerseyapc.nhs.uk/index.html .
If you require further information / assistance please contact Mike Welsby on ext 1565 or
mike.welsby@sthk.nhs.uk.
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14. ANTIMICROBIALS
The use of antimicrobials, including antibiotics, antifungals and antivirals is detailed within
the Trust Antibiotic Policy and supporting Antibiotic Guidelines
Click this link or the logo below to go to the Antibiotic Policy
Smartphone and tablet access to the Trust’s Antibiotic Policy and Guidelines is available
through the Mersey Micro app.
Click the link to find out more
The Trust supports the UK Antibiotic Guardian initiative.
This link takes you to Trust guidance about what you can do to be an antibiotic guardian.
15. OUTPATIENT ANTIMICROBIAL THERAPY (OPAT)
This is a scheme to enable patients to receive intravenous antimircobial treatment in the
home setting when appropriate. This is particularly suitable for extended courses of
intravenous antibiotics when it is not possible to substitute with an oral equivalent. This
reduces the need for clinically stable patients to have prolonged inpatient stays simply to
enable intravenous antibiotic therapy. Clinical responsibility and supplies of antibiotics
remain the responsibility of the Trust even though the patients are managed at home and
may have been technically discharged from the Trust’s Admissions/Discharges & Transfers
(ADT) System. Detailed guidance about the OPAT scheme is provided in the Trust’s
Antibiotic Policy via this link.
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16. UNLICENSED MEDICINES
There are two main categories:
1. Drugs which have no MHRA product licence in the UK. This includes drugs licensed in
other countries, drugs manufactured by a specials manufacturer, individually-prepared
medicines made by a pharmacy
2. Off-label use of licensed drugs – ie. prescribed for an indication not listed in the licensed
indications which are detailed in the drug’s summary of product characteristics.
Considerations when prescribing unlicensed medicines for the Trust’s patients:
 Medicines should be prescribed within their licensed indications whenever possible. Offlabel use is only appropriate when there is no suitable product which is licensed and
available for the required indication. Sometimes national and expert guidance
recommends the use of medicines for off-label indications. Examples include
amitriptyline in neuropathic pain and many drugs used in paediatrics & palliative care.
 Medicines which have a product licence for use in the UK by the MHRA will be
prescribed and supplied unless there is adequate justification eg. allergy to excipients,
formulation unavailable
 Prescribers take on extra responsibilities when prescribing for off-label indications or for
unlicensed medicines. There must be adequate clinical justification and medicolegal
consequences should be considered.
 Pharmacists should make the prescriber aware that a prescribed medicine is unlicensed
in the UK.
 Patients should agree to treatment with an unlicensed or off-label drug before it is
prescribed. The process of informed agreement may be performed in the same way
that agreement for treatment with other medicines is gained from patients without
requirement for additional specific documentation.
 A patient information leaflet explaining unlicensed medicines should be provided to
patients. This is available from Pharmacy.
 Patient-specific decisions about unlicensed medicines should be documented in the
patient’s medical records.
 Pharmacy, through the Drug and Therapeutics Group, will regularly review unlicensed
drugs usage and to encourage the use of licensed alternatives where possible.
 Pharmaceutical Quality Control NW (QCNW) guidance on the supply of unlicensed
medicines will be followed within the Trust.
 Supplies of unlicensed medicines may be quarantined whilst quality control assessment
is conducted if the supplier is not a QCNW-approved supplier. This may lead to delay in
supply. Exception to release a quarantined medicine prior to QC test results may only
be made in very urgent situations when the clinical need of a patient provides
justification. The permission of the consultant, purchasing pharmacist and the patient
should be provided.
 Detailed advice is available from Pharmacy Medicines Information on ext 1565
Hyperlink to Pharmacy/DTG guidance on unlicensed drugs
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17. MEDICINES AND CLINICAL TRIALS
The use of medicines, including both investigative medicinal products (IMPs) and licensed
medicines, within clinical trials is strictly regulated.
All clinical research within the Trust is managed by the Trust’s Research, Development and
Innovation (RDI) Department. Research within the Trust is governed by the Trust’s
Research, Innovation and Development Group which is chaired by the Medical Director.
Approval and support of the above is mandatory before any research activity is permitted,
including those requiring the use of medicines.
The RDI Department SOPs may be accessed via this link.
Close liaison is required between the pharmacy lead for clinical trials, the principal
investigator and the RDI department prior to and following commencement of a clinical trial
which includes medicines. This is essential to ensure the safe and successful conduct of
the study in accordance with Trust policy & procedures, pharmacy SOPs, research network
requirements, sponsor requirements (eg. drug company if not the research network) and
MHRA Good Clinical Practice (GCP).
All medicines intended for use within a Trust-approved clinical trial must be managed by
Pharmacy. Medicines storage requirements will be discussed with and approved by
Pharmacy on an individual trial basis.
Supply of medicines for a clinical trial from Pharmacy will only be made if the specifications
of the trial protocol are met.
Code breaking may be required to identify a clinical trial product for specific patients in the
event of an emergency. The trial protocol must specify the procedure to be followed in such
an event and must be followed by pharmacy and other clinical staff.
Adverse events occurring within clinical trials involving medicines will be managed in
accordance with MHRA GCP requirements and must be specified within the trial protocol.
All staff involved with prescribing, storage, supply, administration and management of
clinical trials involving medicines must have received training in accordance with Trust
policy.
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18. NON-MEDICAL PRESCRIBING
Non-medical prescribing is prescribing by specially trained nurses, optometrists,
pharmacists, physiotherapists, podiatrists and radiographers, working within their
competence as either independent and/or supplementary non-medical prescribers (NMPs).
All NMPs will work within agreed local & national policies and within their scope of
professional practice.
All NMPs must prescribe in accordance with Trust Medicines Policy, the Pan-Mersey
Formulary and other policies relating to prescribing
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Definitions
 Independent prescribing
Prescribing by a practitioner (e.g. doctor, dentist, nurse or pharmacist) responsible and
accountable for the assessment of patients with undiagnosed or diagnosed conditions
and for decisions about the clinical management required, including prescribing.
 Independent non-medical prescriber (IP)
A specially trained nurse or pharmacist who can prescribe any licensed or unlicensed
medicine, including schedule 2-5 controlled drugs, within their clinical competence
 Supplementary prescriber (SP)
A voluntary partnership between a doctor (Designated Medical Practitioner, DMP) and a
supplementary prescriber (SP) to prescribe within an agreed patient-specific clinical
management plan (CMP) with the patient’s agreement.
 Designated Medical Practitioner (DMP)
A doctor who agrees to supervise NMPs throughout their period of training and practice.
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Scope
 Prescribers who qualified prior to joining the Trust must apply, in the same way as a new
prescriber, to prescribe in their new role.
 NMPs who change their role within the Trust must have their competencies ratified by
their designated medical officer/ mentor and apply in the same way as a new prescriber,
to prescribe in their new role.
 The policy does not include Registered Nurses, Midwives or Pharmacists employed
through the staff bank or locum agencies.
 The policy does not include qualified non-medical prescribers employed by the Trust
where the Trust does not support their role as a prescriber.
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Responsibilities
Non-Medical Prescribing Lead (Deputy Director of Nursing & Midwifery)
On behalf of the Trust the appropriate prescribing lead will:
a. Formulate the non-medical prescribing policy.
b. Determine the applicant has appropriate qualification and experience to undertake the
course.
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c. Determine that there is a clinical need within the applicant’s role to justify prescribing.
d. Recommend the non-medical prescriber to the Trust Board for written authorisation to
practice
e. Maintain a register of the individuals’ copy of the NMC / GPhC statement of entry into
the professional register and forward a copy to the individual’s line manager for
inclusion into the personal file.
f. Cascade relevant information to NMPs.
g. Provide a regulatory/ advisory role to the NMPs.
Pharmacy
The Clinical Pharmacy Services Manager on behalf of the Head of Pharmacy is responsible
for:
 Advising the Trust on aspects of legislation relating to Non Medical Prescribing.
 Maintaining up to date registers, including signatures, of:
o active non-medical prescribers.
o non-medical prescribers prescribing controlled drugs
The pharmacist clinically verifying the prescription is responsible for ensuring the prescriber
is authorised by the Trust to prescribe.
Trust Designated Medical Practitioner (DMP)
Is a registered medical practitioner who;
 Has at least three years recent clinical experience in the relevant field of practice.
 Is a consultant, registrar or speciality doctor within the Trust
 Has experience in teaching training or supervising practice
 Has support of the Trust in acting as the DMP
 Is familiar with the NMP programme and the need for the trainee to achieve the
learning outcomes.
 Has agreed to be the DMP for a named NMP trainee
 Is responsible for facilitating 90 hours/ 12 days clinical practice supervision, to
support and develop the NMP trainee’s competencies in prescribing.
Line Manager
The line manager is responsible for
 Supporting the application procedure: When signing the application of a candidate
for NMP training, the line manager is confirming that the applicant is capable of
carrying out non-medical prescribing within the role, including ability to assess and
diagnose the patient’s condition.
 Ensuring that the employees job description / Knowledge and Skills Framework
(KSF) includes a clear statement that prescribing is part of that employee’s role.
 Monitoring prescribing by the non-medical prescriber
 Supporting professional development for NMP and ensuring that the NMP has met
with at least the minimum annual mandatory Trust CPD requirements to allow the
NMP to continue prescribing.
 Ensuring the NMP prescribes within their designated role.
The Non Medical Prescriber
It is the responsibility of the non-medical prescriber to:  Practice within the legal framework and codes of professional practice and conduct as
determined by their regulatory bodies
 Maintain standards of proficiency regarding prescribing practice.
 Provide annual self-declaration to the NMP lead to confirm continuing practice having
undertaken appropriate measures to maintain competency.
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

Where relevant, provide annual self-declaration to the NMP lead to confirm intention to
prescribe controlled drugs having undertaken appropriate measures to maintain
competency.
Attend minimum of one mandatory CPD session per year and undertake other
appropriate CPD to maintain competency in own area of prescribing.
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Authorisation for NMPs to practice within the Trust
 All independent and supplementary prescribers must have undergone the appropriate
training and have written evidence of qualification.
 All independent and supplementary prescribers must have received their prescribing
qualification registered with their professional body (NMC or GPhC) and have a unique
prescribing registration number.
 All supplementary and/or independent prescribers must have written authorisation from
the Trust to practice as a supplementary and/or independent prescriber.
 Copies of the individual authorisation will be kept by:
o The individual
o The appropriate prescribing lead (i.e. for nursing, pharmacy or midwifery)
o The Pharmacy department
o The line manager
 Each independent or supplementary NMP will provide specimen signatures and their
unique registration number to be kept in a register in the pharmacy department to allow
the necessary prescription checks to be made.
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Steps to be followed upon completion of training
 It is the individual NMP’s responsibility to forward 2 copies of the NMC/ GPhC statement
of entry in the professional register, verifying annotation onto the register to the Trust
leads. One copy will be placed into the practitioner’s personal file and one copy will be
retained by the Trust leads.
 Before commencing prescribing duties the nurse will have a meeting with the relevant
Trust lead in order to clarify details and receive supporting procedures including the
written authorisation to practice.
 The Trust leads will contact the relevant line manager to ensure prescribing
responsibilities are added to the non-medical prescriber’s job description.
 The non-medical prescriber may prescribe only after the qualification has been recorded
on the professional register and steps have been completed.
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Independent Non-Medical Prescribing
 A Nurse Independent Prescriber (NIP) must be a 1st level registered nurse, Registered
Midwife or Registered Specialist Community Public Health Nurse whose name in each
case is held on the Nursing and Midwifery Council professional register, with an
annotation signifying that the nurse has successfully completed and approved
programme of preparation and training for nurse independent prescribing.
 A Pharmacist Independent Prescriber (PIP) must be a registered pharmacist, whose
name is held on the membership register of the GPhC, with an annotation signifying that
the pharmacist has successfully completed an education and training programme
accredited by the GPhC and is qualified as an independent prescriber.
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


Nurse and Pharmacist independent prescribers can prescribe any licensed medicine for
any medical condition within their competence. This includes Controlled Drugs in
schedule 2-5 of the Misuse of Drugs Act 1971, with the exception of cocaine,
diamorphine and dipipanone for the treatment of addiction.
Nurse and Pharmacist prescribers can prescribe medicines for uses outside their
licensed indications for patients on the same basis as doctors provided they are
competent and take full responsibility for doing so.
Nurse and Pharmacist prescribers can prescribe medicines for uses outside their
licensed indications / UK marketing authorisation (so called “off-licence or off-label”)
provided they are competent and take full clinical and professional responsibility for their
prescribing and should only prescribe ‘off-label’ where it is considered best practice to
do so.
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19. TRANSCRIBING OF PRESCRIPTIONS BY 5TH YEAR MEDICAL STUDENTS,
PHARMACY and OTHER STAFF

The Trust’s Clinical Education Team manage a scheme to enable 5 th year medical
students to transcribe prescriptions under close supervision. Any prescription written by
a student must be stamped to clearly indicate that it was written by a student. The
supervising foundation stage doctor or senior doctor must check and authorise/sign the
prescription and undertake full clinical responsibility. Under no circumstances may a
student write up a controlled drug.

Registered pharmacy staff, when given permission to do so, may complete the list of
current medicines on the ICE TTO. This task involved transcribing the current list of
medicines from the inpatient kardex(es) into ICE. However, these staff must must NOT
submit or authorise TTO. They can only input and save. Authorisation may only be
conducted by a foundation stage doctor or registered doctor who will take full clinical
responsibility.

Other staff may include registered nurses and midwives eg. nurse specialists who will
pre-write prescriptions which will then be checked and authorised/signed by a registered
doctor or foundation stage doctor.
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20. PATIENT GROUP DIRECTIONS (PGDs)



A Patient Group Direction is a written instruction for the supply and administration of
medicines without a prescription to groups of patients who may not be individually
identified before treatment
Certain healthcare professionals within the Trust are authorised to supply and
administer medication under a PGD. All such directions must be developed in
accordance with the Trust Policy on the Development of Patient Group Directions and
be approved by the Trusts Drug and Therapeutics Group
The person named in each direction is not authorised to delegate to a second
person the administration or supply of the drug specified. Therefore all such
drugs must be administered or supplied directly to the patient by the practitioner
named in the direction
Click here to go to the Trust Policy for Patient Group Directions (PGDs)
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21. DRUG HISTORY TAKING AND MEDICINES RECONCILIATION
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ROLES
The admitting doctor
As part of their admission history in the patient’s medical notes, should compile a drug
history/list of medicines the patient has been taking prior to admission. This should include:
 Name of medicine
 Dose
 Route
 Frequency
 Allergies (and other important warnings)
If this information is not available or is unclear, this should be documented in the admission
history.
Pharmacist
As soon as possible after admission (ideally within 24 hours) a pharmacist should
undertake a medicines reconciliation to ensure the medicines prescribed on admission
correspond to those the patient was taking before admission; taking into account any
appropriate changes made to the patient’s prescription eg. dosage change or drug omission
due to adverse event.
Pharmacy Technicians/Pre-Registration Pharmacist
To assist the pharmacist in drug history taking and medicines reconciliation as follows
 Compile the list of medications the patient was taking before admission as detailed
below under drug history taking. This should include over the counter medicines as well
as those medicines that have been recently changed or stopped
 Document the list of medicines on the specific medication history form
Nursing & Midwifery Staff
Nursing & midwifery staff should ensure where possible that patient’s own medicines are
kept with the patient on admission to facilitate the reconciliation process
DRUG HISTORY TAKING
This may also be carried out by the admitting doctor/NMP, by pharmacy staff or by nurses
working in pre-admission clinics. Amongst Pharmacy staff, this task can be performed by a
pharmacy technician, a preregistration pharmacy graduate or a pharmacist.
Collecting Information
GP referral letters, hospital medical records, the patient, carer, nursing homes, community
pharmacists and GP surgeries can all provide information on individual drug histories.
However, each of these sources has its limitations.
Patient/Carer
The patient/carers who have knowledge about the patient’s medication are the best
source to obtain information from, as they can provide accurate and up-to-date drug
histories. Alternative sources of information (listed below) may need to be used in
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patients with communication difficulties or if the patient/carer is unclear about the
medicines they usually take at home.
The patient should be consulted initially regarding their medication:
 Confirm the patient’s name & date of birth
 Confirm allergy status
 Has the patient any medication with them (see Patients Own Drugs PODs below)
 Has the patient a list of their medication (it is important to check the date of issue
on each prescribed medicine on the script, as discontinued drugs tend not to be
cancelled from the script until the patient has a medication review)
 Ask if the patient takes or uses any other medication e.g. inhalers, eye drops,
creams etc
 Ask if the patient takes any Herbal or OTC products
 Ask if there have been any recent changes to the patient’s medication e.g. any
medication recently discontinued
 Confirm the patient takes the medication as directed
 (Alternative formats available on request, e.g. translation services, sign language
services).
Patient Own Drugs (PODs): If the patient has brought their own medications in to hospital,
these must be checked using the POD algorithm for suitability of re-use. Check if the PODs
are labelled with the current doses and if the patient is still taking them.
Relatives/Carers may also be used as a source to confirm a patient’s current medication
details (although consideration must be taken to assure patient confidentiality).
 Relatives/Carers should be encouraged to bring in patient’s own medication
 Relatives/Carers should be encouraged to bring in the patient’s repeat prescription
requests
General Practitioner (GP) Referral Letter
Patients who are referred by their GP may bring a referral letter with them, which
details their current medication and drug allergies. Unfortunately, such letters are often
far from complete. A number of studies have shown omitted drug details and incorrect
information on such letters – see below in SCR information.
Summary Care Record (SCR)
Most patients of St Helens and Knowsley localities have consented to their GPs sharing
electronic summary health record information onto the NHS Summary Care Record.
Information on current and previously prescribed medicines is available on SCR. Access to
SCR is via Smartcard for specifically approved staff. Permission from patients must be
sought before accessing a patient’s summary care record. This must be recorded when
accessing the system. In emergencies when gaining permission is not possible (eg. if
patient is unconscious and a carer/relation is not available), access may be obtained but
recorded as emergency access.
It is essential to remember the GP records may not list all medicines which a patient is
currently taking. Specialist medicines such as ‘memory drug’ for Alzheimers disease,
antipsychotic drugs, biologics, clinical trial drugs, ongoing cancer chemotherapy etc may
not be recorded. Over the counter (OTC) medicines and herbal/homeopathic medicines will
not be listed.
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Users of SCR are advised to check the last supply date on SCR as this will give indication
of how up to date the record is.
Contacting the GP Surgery
This can be a good source to acquire information, particularly for patients who are not listed
on SCR. There are a number of issues to take into consideration to ensure you are
receiving ‘up-to-date’ and accurate information (also see text above in SCR)
 Has the patient been in hospital or attended a clinic recently where a hospital clinician
may have made changes to their drug therapy, which the GP has not yet been notified
of?
 The patient may have had a recent consultation with the GP, who may have given
verbal instructions on medication changes, which are often only recorded in the paper
notes with no alterations made to the computer records until sometime later
Where the medication history is incomplete, the GP Surgery must be contacted and a
faxed copy of the recent medication history requested.
The GP surgery details must be obtained from the patient notes
The GP receptionist must be contacted via telephone and informed of the following:
a) Name of pharmacist/technician
b) Hospital and ward
c) Name, date of birth & address of patient
d) Request via fax an up-to–date list of patient’s current medication list including
acute medication & allergy status.
e) Ask for the GP surgery fax number & notify that this request will be faxed on a
“Request for Medication Details” form (see Pharmacy SOP)
f) Clinical details regarding the patient must not be discussed.
 Once the fax has been obtained the patient’s name & date of birth must be highlighted
(underlined/circled) on all pages to avoid incorrect medications being prescribed to the
wrong patient
 The date of administration must also be highlighted to ensure it is the most up to date
record
 The hard copy and the fax request slip should be placed in the patient’s notes for
reference
Nursing Home
Nursing homes are a very reliable source and can inform you exactly what the patient
has been taking, as they tend to administer all medicines to their residents. The majority of
nursing homes will send a computerised medication administration record (MAR) into
hospital with the patient.
It is also useful to check if a supply of medicines will be required by the nursing home on
discharge.
When contacting the nursing home follow the steps as for GPs above:
 Once the fax has been obtained the patient’s name & date of birth must be highlighted
(underlined/circled) on all pages to avoid incorrect medications being prescribed to the
wrong patient
 The date of administration must also be highlighted to ensure it is the most up to date
record
 The hard copy and the fax request slip should be placed in the patient’s notes for
reference
Community Pharmacist
This is another source from which to acquire information from, relating to drug
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histories, as many community pharmacies maintain computerised patient medication
records. However, it is essential to understand that patients may not use the same
pharmacy all the time.
The community pharmacist can help in confirming if the patient requires a compliance
aid and which device they normally use
Hospital Records
The Electronic Document Management System (EDMS) provides quick access to scanned
medical records and correspondence from previous admissions or appointments in the
Trust.
A recent TTO form may be useful to obtain up-to-date information if the patient has had a
recent episode in hospital.
The patient’s medical records are a good source to obtain information if the patient has had
a recent episode in hospital or attended a clinic. If the clinician in the hospital has made
changes to the medication regime, this should be documented in the medical notes (a copy
of the letter to the GP following discharge will also be in the notes and should provide
information on changes to therapy).
It is essential to remember that when obtaining information from medical records or the
Pharmacy JAC system that you are assuming that an accurate drug history was taken on
the last admission (if regular medication were omitted non-intentionally on the last
admission there would therefore be no record in the notes or JAC system)
Other useful sources
Drugs teams eg Addaction, Lighthouse Project for methadone dose confirmation
MEDICINES RECONCILIATION
Once all the relevant drug history information has been obtained:
 Compare the confirmed medication history with the medication prescribed on the
patient’s prescription kardex.
 √ Place a tick in the pharmacy section of the drug chart beside the medications the
patient was taking on admission
 Ensure any discrepancies are rectified. Technicians should make their ward pharmacist
aware of any discrepancies. The pharmacist will ensure these are rectified with
medical/nursing staff.
Remember certain alterations to a patient’s medication may well be intentional eg.
reduced doses in renal impairment.
Communicating Information:
 Alterations to a patient’s medication must be annotated by the ward pharmacist in the
pharmacy section of the inpatient prescription kardex eg. dose increased on admission
or dose reduced due to poor renal function etc.
 Stopped/Withheld medications and the reasons why should be annotated by the ward
pharmacist on the patient’s kardex (in the space available at the top of page 2 of the
inpatient prescription kardex).
 Newly started medications and the reasons why should be annotated by the ward
pharmacist in the pharmacy section of the kardex e.g. digoxin – AF
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Documentation of medicines reconciliation
Once an accurate medication history has been confirmed this must be transcribed into
the patient’s medical notes. The entry must be signed, dated and timed and all sources
used to confirm the drug history stated.
The appropriate section of the kardex must also be completed to confirm an accurate
medication history has been taken.
Pharmacy Technicians must have completed the Pharmacy Drug History Training
Module in order to transcribe directly in to the patient’s medical notes. Technicians
who have not completed this module should communicate the drug history to the
ward pharmacist who in turn must enter this in to the notes. The Medication History
Form may be used by untrained technicians.
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22. ACCURACY CHECKING OF PRESCRIPTIONS
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
n)
Supplies of medicines for individual patients from Pharmacy may only take place after
a pharmacist has checked the prescription. This is termed a clinical check (or
alternatively a professional check). The clinical check can take place in any
appropriate location. This will usually be on a ward or within Pharmacy.
Guidance on the professional checking process is provided to pharmacists within the
Pharmacy SOPs.
A pharmacist has authority to make amendments to prescriptions in accordance with
guidance detailed in Pharmacy SOPs.
A pharmacist has authority to refuse or to withhold supply of medicines if the
prescription is considered unsafe. In such circumstances the pharmacist will take
action to ensure the prescription is made safe, taking account of the patient’s condition
and priority of treatment. Usually such action will involve liaison with the prescriber to
confirm their intentions or any amendments required. If the prescriber is not available
and correction is urgent, the pharmacist will seek the assistance of another prescriber.
If a prescriber does not agree to a pharmacist’s advice but the pharmacist still believes
the prescription to be unsafe, they must consult a more senior doctor. Support from a
senior pharmacist may also be sought.
Each pharmacist performing a clinical check on a prescription will sign or initial the
prescription for non-stock inpatient, discharge, day-case and outpatient prescriptions
in accordance with Pharmacy SOPs.
A signed clinical check for a medicine gives authorisation for technical staff in
Pharmacy to dispense the medicine in accordance with the details on the prescription
or requisition.
The clinical check of requisitions for named inpatients and for discharge prescriptions
requires the pharmacist to check for transcription errors against the inpatient
medicines kardex. Authorisation of supplies for such patients without seeing the
inpatient kardex should only be in exceptional circumstances. If a supply is authorised
without the kardex, measures should be taken to satisfy the pharmacist that it is safe
and in the best interests of the patient to do so. This is a matter of professional
judgement.
Pharmacists will be scheduled to visit wards in the hospital to review inpatient
prescriptions within a near-patient environment.
Where possible wards are visited by a pharmacist each day (Monday to Friday) and
every patient will be reviewed during their admission.
On Saturday mornings all wards are visited by pharmacy staff to review new
prescriptions with them aim of preventing need to sending kardexes to pharmacy and
to organise any stocks required.
Medical wards receive clinical pharmacy visits on Saturdays and Sundays in order to
review new patients and to support discharges
When resources do not permit daily visits and reviews of every patient, the Head of
Pharmacy has authority to prioritise service delivery. Critical Care, SCBU,
Haematology, Paediatrics, AMU and SAU are given highest priority. A lower level of
ward pharmacist visit may be provided to other wards. If no service can be provided
to a ward this must be authorised by the Head of Pharmacy (or deputy). These
occurrences will be reported on Datix and presented at the Clinical Performance
Council as part of the prescribing accuracy update reports.
Pharmacists will seek to review new patients and reconcile drug histories as soon as
possible after admission. Pharmacy technicians with extended skills may assist in
obtaining and confirming drug histories.
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o)
p)
q)
When a pharmacist is not available to check a prescription, greater responsibility is
placed upon nurses and midwives administering medicines to ensure it is safe to do
so. If there is any doubt, even after checking standard reference sources and with
other nurses, the prescriber or Pharmacy should be contacted for advice about the
concern.
Out of hours supplies of medicines for discharge are available on some wards &
clinics. These enable the dispensing of commonly required medicines without the
need for a prescription to come to Pharmacy for dispensing. Each ward operating
such a facility has an SOP for its use. It is the responsibility of the ward manager to
ensure that all staff using the facility can safely follow the SOP. In the absence of a
pharmacist, each prescription will require a second check by another registered nurse,
midwife, doctor or pharmacist to ensure it is safe to make a supply as prescribed.
Similar facilities to the out of hours supplies described above are being made available
for use in specific clinical areas during normal hours. The processes and
responsibilities are very similar to the out of hours procedures.
Click to go back to main contents table
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23.
PROCUREMENT AND SUPPLY OF MEDICINES
Staff are reminded that medication supplied to each clinical area is for administration
the patients under the care of the Trust only. Misappropriation or theft of medicines
by staff constitutes gross misconduct and will be managed in accordance with the
Trust’s disciplinary procedure. Such instances may be classed as Fraud and matters
will be referred to the Trust’s Local Counter Fraud Specialist (LCFS) to investigate.
Reporting to the appropriate professional body will be strongly considered. (See
section on Suspected Theft or Fraudulent Procurement of Medicines).
Supplies from Pharmacy can only be provided against prescriptions, requisitions
and signed orders provided on official Trust stationary or media eg. e-top up, eprescribing.
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PURCHASING OF MEDICINES
Medicines are unlike any other items of commerce and for this reason the purchase,
storage and distribution must be under the control of a pharmacist.
The Trust Standing Financial Instructions (contained in the Corporate Governance Manual)
delegates the financial responsibility, within pre-set limits, for tenders and the signing of
orders for medicines to the Head of Pharmacy and authorised deputies.
Medical, nursing, technical and other staff are not permitted to undertake contracting or
tendering for, or purchasing of medicinal products intended for administration to patients
within the Trust.
Medicines procurement contracts
 MHRA-licensed medicines suppliers will be used
 NHS Commercial Medicines Unit (CMU) co-ordinated NW regional medicines contracts
will be used whenever possible
 The Trust will participate in the NW Regional medicines contracts and comply with the
terms and conditions required
 The Trust will provide medicines purchasing data to the NHS CMU via Pharmex data to
enable drug contract tendering, scoping and contract performance monitoring on the
Trust’s behalf.
 Where NHS CMU contracts are not available, whenever possible the Trust will procure
drugs through a supplier listed on a NW Regional SBS tender framework (or similar).
Frameworks are presently available for pharmaceutical wholesalers, homecare delivery
and specials (unlicensed medicines) suppliers
 Off-contract purchasing of medicines wil only occur when contrated suppliers are unable
to supply or when a contracted product is unsuitable for Trust requirements. The Drug &
Therapeutics Group will review proposals for planned off-contract purchasing. Planned
decisions to purchase off-contract will be communicated with the NHS CMU and the NW
technical services pharmacist for procurement.
 Trust pharmacy staff will participate in NW pharmaceutical procurement groups and
tender adjudication
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Quality of purchased medicines
 Drug contract tenders, adjudication and post-award monitoring involve significant and
direct input from Quality Control NW, our NHS hospital pharmaceutical quality control
service to which the Trust subscribes. Quality requirements and QC analysis are major
components in contract specifications.
 Concerns regarding quality of medicines can occur and all staff involved in the use of
medicines are requested to be vigilant for these. Concerns can include matters such as
unclear labelling, cloudy liquids, broken ampoules, insoluble material etc.
 If a problem arises as a result of poor quality it must be reported promptly to the
Pharmacy so that action can be taken. Action will include reporting to QCNW. A
national pharmacy network exists for reporting and disseminating drug defects to ensure
patient safety and MHRA awareness.
Quality of unlicensed medicines
All unlicensed products purchased for use within the Trust must be checked by the
Pharmacy before issue. There may be delay in the availability of medicines whilst quality
control analysis is performed, but this ensures that the quality and efficacy of these
medicines (for which the Trust must take some liability) is suitable for their intended use.
See section on unlicensed medicines
Free samples of medicines for professional use
All free samples provided by drug companies for use within the Trust must be authorised by
the Drug and Therapeutics Committee and issued through the Pharmacy Department. Any
samples supplied directly to clinicians must be provided to pharmacy for assessment before
they are made available for patient use.
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SUPPLY OF CONTROLLED DRUGS (CDS)
Please refer to the Trust Policy for the Management of Controlled Drugs and related
procedures for further advice.
Refer to Pharmacy departmental SOPs for Pharmacy-specific information about supply of
CDs
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SUPPLY OF CYTOTOXIC CHEMOTHERAPY (INCLUDING METHOTREXATE)
Separate polices exists for intrathecal chemotherapy, vinca alkaloids and oral
chemotherapy. Click here to locate these policies on the Medicines Resources
Intranet Site
a) Unless supplied ready for use, injectable cytotoxic drugs MUST be prepared in
Pharmacy or Clatterbridge Centre for Oncology. The only exception is when
methotrexate used in tubal pregnancy termination in a specialist obstetrics and
gynaecology ward or clinic.
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b) Pharmacy should receive adequate advance warning of intended injectable
chemotherapy, even when this is provisional and the final decision to prepare and
administer the medicine depends, for example on the patient’s blood count
c) Only specially-trained, designated Pharmacy staff may prepare cytotoxic chemotherapy
d) The required medicines are prepared by the Pharmacy to be ready for use at the time
indicated and should be administered as soon as possible after receipt. Some
medicines deteriorate rapidly after reconstitution. Contact the Pharmacy Aseptic
Dispensing Unit on ext 1514 if further advice is required.
e) Storage conditions must be noted and the cytotoxic drugs must be kept separate from
other drugs
f) Methotrexate. Methotrexate is commonly prescribed for Rheumatology and
Dermatology patients. As per national and local health economy policy, the only
strength of methotrexate tablets which will be supplied will be 2.5mg. The dose of
methotrexate for these patients will be once per week. If any other dose frequency is
prescribed, a supply will not be made until the correct dose and frequency is verified.
Prescriptions with the dose and frequency ‘as directed’ will not be dispensed. Specific
procedures and guidance are available for the use of methotrexate in accordance with
NPSA recommendations.
g) Non-cancer indications. Cytotoxic chemotherapeutic drugs are being used more
commonly for indications outside of cancer/haematology. At the present time
cyclophosphamide and rituximab are being used intravenously in rheumatology,
methotrexate injections in rheumatology and irrigations of mitomycin in Urology. The
same standards of supply and handling are required in these locations as in cancer
wards & clinics. Please contact Pharmacy for specialised advice.
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SUPPLY AND DISPENSING OF MEDICINES FOR INPATIENTS
Clinical pharmacists visit designated wards on a scheduled basis. The pharmacists’ duties
include checking patients’ ward and discharge prescription documents and arranging
supplies of non-stock medicines.
Pharmacists will check patients’ medicines kardexes in accordance with the section on
accuracy checking and the relevant Pharmacy SOP. Endorsements include the following:
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If the allergy status is not written, take action to ensure it is completed
Any special instructions relating to administration
Sign their initials in the appropriate box(es)
The date the item was checked and the ward where it is to be supplied
Write ‘POD’ if the patient’s own medicine is to be used and the quantity if
appropriate
For rewritten kardexes, the chart rewritten box should be signed and dated after
checking items against the previous kardex
Stock drugs do not require endorsement
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Non-stock medication
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Non–stock medication will usually be supplied by the Pharmacy as an original pack of
medication labelled with the patient’s name, the approved name of the preparation and
administration instructions. Proprietary names will only be used when the proprietary
name defines a specific formulation or combination (e.g. slow-release theophylline
preparations). Drugs with frequently changing doses and also injections & infusions
may be supplied to the ward without the inclusion of instructions for administration on
the label. If multiple patients are taking changing doses of the same medicine then
supply to the ward as a temporary stock line may be appropriate.
Medicines which have been dispensed in original packs with directions for administration
should be stored in the patients’ bedside medicine cabinets. These medicines are
suitable for patients’ to take home on discharge provided there is sufficient quantity. If a
patient is transferred to another ward it is essential that these medicines are transferred
with them.
Patients’ own drugs may be re-used in hospital, but they must first be inspected and relabelled if necessary, in accordance with the relevant pharmacy SOP. Patients’ own
drugs must not be administered until they have been positively identified.
If the clinical pharmacist has already visited the ward earlier in the day and there are no
arrangements to return, then the medicine kardex should be sent to the Pharmacy at the
earliest opportunity to order the medication. If the patient has more than one kardex
then they should ALL be sent to the pharmacy. (Critical Care Unit do not need to send
their Kardexes to Pharmacy).
Dispensing for discharge (one-stop dispensing)
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This system has the benefit that all regular, non-parenteral medicines are individually
dispensed for each patient ready for discharge. Every patient, soon after admission, will
be supplied with 28 days of medication fully labelled with instructions for use (except
controlled drugs and changeable treatments)
The medication is stored in a locker by each patient’s bed. Pharmacy technicians visit
the ward regularly to review each patient’s medicine kardex and order new items if
required. Items where the dosage has changed will be relabelled by the Pharmacy if
necessary. This system is used in conjunction with the reuse of patients own drugs
scheme.
Ward/Department medicine stocks
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Many medicines will be held as stock on wards/depts. A copy of the stock list is held on
the ward and additional copies will be supplied on request. Ward managers may
request changes at any time and need to sign the list each time a new copy is produced.
Pharmacy Technicians and Pharmacy Assistants visit wards and departments regularly
to top-up stock medicines.
Some wards are participating in trials with Pharmacy to modify and improve stock
medicines supply systems.
In the event of stocks of a medicine running short before the next top-up, one of the
ward Pharmacy staff regularly visiting the ward should be informed. If the supply is
urgent and required before Pharmacy staff next visit, the ward stock top-up sheet should
be filled-in with the required extra medicines and sent to Pharmacy without delay.
In the event of an urgent shortage of stock or any other medicines outside of normal
hours, please call the on call pharmacist (via Switchboard) for advice.
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Medicines optimisation – understanding the patient’s experience
Up to 50% of patients do not take their medicines as recommended. To ensure the best
possible outcome from medicines, there must be an ongoing, open dialogue with the patient
and/or their carer(s) about the patient’s choice and experience of using medicines to
manage their condition. It must be recognised that a patient’s experience may change over
time even if their medicines do not.
Pharmacy staff will support and develop medicines optimisation, helping patients to get the
most from their medicines on an individual basis. This support will include promotion and
support for medicines optimisation being carried out by all appropriate members of the
clinical teams, not just Pharmacy staff.
Returning Medicines to Pharmacy
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The SOP for safe storage and security of medicines gives details about returns
All stock and individually dispensed medicines which are no longer required should be
placed in a Pharmacy Delivery Bag/Box (or specialist returns bin) and sealed. A goods
return form must be completed. The person taking the box from the ward to Pharmacy
must sign the form and take this, along with the bag/box and return it to the Pharmacy
Department as soon as possible. A copy of the completed form remains on the ward.
Pharmacy will sign and retain the form upon receipt of the sealed box/bag.
Medicines which are suitable for re-use are returned to stock by Pharmacy and the
ward/dept will be credited. All other medicines will be destroyed.
Anyone unsure of how to dispose of, or to return a particular item should seek advice
from Pharmacy before taking action.
Patients own medicines remain the patient’s property. If they are no longer required,
they should be securely returned (with the patients permission) to Pharmacy for
destruction.
Dispensed for discharge and patients own medicines may be required by Pharmacy
when dispensing discharge medicines. The medicines transfer books must be used to
provide an audit trail for such returns.
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DISPENSING OF DISCHARGE PRESCRIPTIONS (TTOs)
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TTOs should ideally be received in Pharmacy before 3.30pm on weekdays to avoid
delays in discharge and inconvenience to patients and their carers.
Patients must always be dispensed supplies of medicines which comply with current
legal and good practice requirements.
Patient information leaflets must be provided within all packs of dispensed medicines
wherever possible. Additional leaflets and cards will be provided or updated for
specific medicines eg. steroids, anticoagulants, mono-amine oxidase inhibitors
(MAOIs).
Compliance aids such as spacers for inhalers must be specified upon prescriptions to
ensure supply. Pharmacy staff will routinely query obvious needs eg. spacers for
inhalers, but this should not solely be relied upon.
5ml spoons will be supplied as standard for administering liquid medicines.
Administration instructions will be in multiples of 5ml spoonfuls.
Oral syringes will routinely be supplied for young children and for adults requiring
doses which are not multiples of 5ml. A separate oral syringe will be supplied for each
prescribed liquid. Each syringe will be marked to indicate the volume of liquid to be
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drawn up. A bung to fix into the neck of each bottle will be supplied along with an
instruction leaflet.
Process for Discharge Prescriptions (TTOs)
 Doctors are responsible for ensuring that TTO prescriptions are written leaving
sufficient time for them to be checked and dispensed without delaying discharge.
 Wards should endeavour to retain newly written TTO prescriptions on the ward until
the pharmacist or pharmacy technician visits at their agreed time. Those wards
provided with a TTO bleep service should bleep the pharmacist/technician when
there is a new TTO on the ward ready for checking. The ward pharmacy staff will
check the TTO against the inpatient kardex for transcription errors and other
problems, allowing the kardex to be retained on the ward.
 In the absence of ward pharmacy staff being available, the TTO prescription plus the
corresponding inpatient kardex(es) must be sent to Pharmacy giving sufficient time
for them to be dispensed and returned to the ward before the patient is discharged,
ideally 24 hours. Any medicines which have been individually supplied and labelled
for the patient being discharged (and usually stored in their bedside medicines
cabinet) must be sent to Pharmacy along with the prescription and the kardex.
 The date and if possible, the time of discharge should be written on the TTO
prescription (ICE does this automatically).
 The prescriber are encouraged to prescribe every medication that the patient is
taking and not just those that are required for discharge. Where supplies of
medicines are not required this should be indicated. Each patient will normally
receive at least 14 days supply from Pharmacy (more may be given over a bank
holiday). This should allow sufficient time for the discharge letter to get to the
General Practitioner (GP) before replenishment of their supplies is necessary.
 In an emergency, out of hours, the on-call Pharmacist should be contacted for
advice; pre-packs are available in Accident and Emergency Rooms and on some
wards. Pharmacy does NOT routinely dispense TTOs out of hours.
 Nurses MUST NEVER ‘dispense’ from general ward stock for patients going home
as this is specifically prohibited within the terms of the Medicines Act 1968. The
Trust will accept no responsibility should a drug related incident occur in these
circumstances. Provision for emergency and out-of-hours supplies of medicines are
detailed in section 2.11.
 On discharge, nurses may supply/hand over to patients their ‘patients’ own
medications’ and medications dispensed ‘ready for discharge’ by Pharmacy eg.
original packs, non-formulary drugs, inhalers, topical formulations and other drugs
labelled for that patient with instructions for use. These medicines are usually kept in
the patient’s bedside medicines locker. The TTO will be endorsed “from ward” or
“POD” by Pharmacy for such drugs when they have not been dispensed and
supplied in the bag along with other TTO medicines.
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DELIVERY OF DRUGS, RECEIPT OF DELIVERIES & COLLECTION FROM
PHARMACY
Click here to go to the SOP for safe storage & security of medicines which gives details
about delivery and collection
Liquid nitrogen will only be delivered in well-maintained, dewar flasks, specifically
designed for this use.
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DISPENSING OF MEDICINES FOR OUTPATIENT PRESCRIPTIONS
Prescription charges and exemptions.
 Prescription charges at the national rate will apply to all non-exempt patients.
Information upon pre-payment will be provided to patients where this may help
them to reduce the financial burden.
 If payment cannot be made, a reduced emergency supply will be made. The
patient will be requested to return for the rest of the prescribed quantity along with
payment.
 Proof of exemption or pre-payment will be required from patients claiming
exemption.
Signing backs of prescriptions.
The details required on the backs of the prescriptions, including signatures are
required from patients, relatives or messengers must be completed.
Patient information leaflets
Patient information leaflets should be provided within all packs of dispensed
medicines. Additional leaflets and cards will be provided for specific medicines eg.
steroids, anticoagulants, MAOIs, lithium.
Compliance aids
Compliance aids such as spacers for inhalers must be specified upon prescriptions
to ensure supply. Pharmacy staff will routinely query obvious needs eg. spacers for
inhalers, devices for insulin injection etc but this should not solely be relied upon.
Liquid measures and instructions
 Administration instructions will usually be in multiples of 5ml spoonfuls.
 5ml spoons will be supplied as standard for administering liquid medicines.
 Oral syringes will routinely be supplied for young children and for adults requiring
doses which are not multiples of 5ml. A separate oral syringe will be supplied
for each prescribed liquid. Each syringe will be marked to indicate the volume
of liquid to be drawn up. A bung to fix into the neck of each bottle will be
supplied along with an instruction leaflet.
Duration of supply
 A maximum of 28 days supply will be dispensed for the majority of outpatient
medicines if a quantity is not specified, unless circumstances dictate that a
different supply is necessary.
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 If a quantity is not indicated, only seven days supply of antibiotics, short term
hypnotics and analgesics will be provided. Single original packs of inhalers,
topical preparations and other devices will be dispensed.
 No more than 14 days supply will be dispensed to any patient considered to be
at risk of suicide.
 7 days supply will usually be provided for prescriptions from Accident and
Emergency.
 Longer durations of supply can be made in some situations including:
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Hospital only medicines - these cannot be prescribed by GPs
 Clinical trial medicines
 Pulsed / cyclical treatment
 Antidepressants prescribed by consultant psychiatrists to ensure
continuity of treatment
 Reducing doses of drugs e.g. steroids
 Drugs for tuberculosis treatment
 Haematology-oncology treatment
 Donepezil (prescribed by named consultants only)
 Drugs to ensure continuous supply over public / bank holidays
 Courses of antibiotics for acute treatment
 When packs cannot be split
 Other situations when it is considered appropriate
Owings
 If Pharmacy does not hold enough stock to make a supply to a patient they will
make arrangements with the patient for notification and collection/delivery when
the supply is obtained. If the prescribed medicine is considered urgent, the
prescriber may be consulted to discuss alternative treatments, should a delay in
treatment be detrimental.
Handover of dispensed medicines
Pharmacy staff may require proof of identification and reserve the right to refuse
hand-over of dispensed prescriptions unless they are satisfied of the authority of
the person collecting. Members of staff collecting prescriptions on patients’ behalf
will be asked to sign the pharmacy record book for collection.
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CONTAINERS
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Child-resistant containers (CRCs) are used routinely on discharge and out patient
items. If a member of the ward staff feels that CRCs would be difficult for the patient to
open, plain tops will be fitted provided that the prescriber writes ‘No-CRC’ on the TTO
or outpatient prescription
The likelihood of children coming into contact with the medicines should be
considered
Liquid nitrogen will only be supplied in suitable, purpose-designed dewar flasks which
are in good condition
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EMERGENCY CARDIAC ARREST BOXES
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Opened cardiac arrest boxes must be returned to the store in the Cardio-Respiratory
Department as soon as possible and a replacement obtained.
The store is usually checked twice a day by Pharmacy staff to ensure there are sufficient
boxes available.
In the event of no boxes being available contact the Pharmacy Department. Out of
hours, the On-Call Pharmacist can be contacted via Switchboard.
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MEDICINES REQUIRED URGENTLY AND IN EMERGENCIES
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During working hours, Pharmacy should be called. In a true emergency scenario it
is imperative that, before relating any details, ward/dept staff ask to speak immediately
to a pharmacist in order to prevent delays.
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Outside of Pharmacy hours, urgent supplies of medicines may be obtained from the
Pharmacy Emergency Supply Room. The Trust Site Managers (Bed Managers) have
access to the swipe card/fob and procedures to access this room. Ward staff should call
the Site Manager to make arrangements for obtaining stock of medicines from this room.
They will need to accompany the site manager to the room with the relevant inpatient
kardex. Documentation and signatures are required for any stock removed from the
room. Pharmacy staff check the room daily to update records and stocks.
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If the medicine is unavailable from the Emergency Supply Room, the doctor or a senior
registered practitioner on the ward should contact the on-call pharmacist via
Switchboard for advice. The on-call pharmacist has on-line access to hospital stock lists
and the Pharmacy computer system and may be able to locate supplies of the medicine
elsewhere in the hospital. Alternative treatments may also be discussed. If supplies of
a medicine are to be obtained from another ward, the procedure for transfer of
medicines must be followed to ensure an audit trail and security is maintained.
Pharmacy is open seven days a week so the need for an emergency supply may also
be discussed. In the event of the medicine not being available on another ward and
confirmation that an urgent supply is necessary, the on-call pharmacist will advise upon
the necessary action. This may involve coming in to dispense the medicine from
Pharmacy stocks or sourcing the medicine from another hospital or wholesaler.
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A list of critical medicines where timeliness of administration is crucial is available. If for
any reason a medicine on this list cannot be administered, the doctor responsible for the
patient must be informed immediately and the appropriate drug omission code should
be used to indicate the reason why. If a patient is likely to suffer a detrimental effect due
to non-administration it is the nurse’s responsibility to take timely action, as outlined
above and an IR1 should be completed. In some situations eg. acute infection, even the
missing of one dose can be serious.
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It is the responsibility of the administering nurse/midwife to ensure the drug is
obtained as outlined above. The non-administration of a medicine in accordance
with a prescription without taking the necessary action to remedy the situation is
a matter of professional misconduct or negligence.
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Medicines for discharge, outside of normal hours. Several locations within the
hospitals have been provided with ‘out of hours’ cupboards. These contain stocks of
pre-labelled, ready for discharge, commonly prescribed medicines. They may be used
outside of normal Pharmacy hours. Standard operating procedures exist for their use.
In brief, only registered nursing, midwifery or Pharmacy staff may dispense from these
cupboards. Packs may only be removed if there is a valid prescription written by an
approved prescriber. The patient’s name and the date of dispensing must be written on
each pack supplied. Details of the packs dispensed must be noted upon the
prescription. The dispensed prescription must be checked by checked by a second
registered nurse/midwife, pharmacist or doctor. At the time of writing, ‘out of hours’
cupboards are available on A&E, Paediatrics, Maternity, Admissions Units.
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Please note that the on-call pharmacist will NOT routinely dispense TTOs.
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Major incidents/pandemics etc. The most senior pharmacist available will liaise with
key Trust staff in accordance with the Major Incident Plans. In order to manage a
particular emergency it may be necessary to waive or vary elements of the Medicines
Policy. This will only be conducted with the approval and instruction of the pharmacist in
charge at the time of the emergency. Approval of other key senior staff eg. Medical
Director, Nursing Director may also be required. Variances will be reported to the Trust
Major Incident Management Team at an appropriate time. Normal practice will be
resumed at the earliest appropriate opportunity.
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OVER THE COUNTER (OTC) MEDICINES
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The Drug and Therapeutics Group will approve the list of OTC drugs sold from retail
outlets within the Trust eg. WHSmith
In the event of staff or relatives requiring an OTC medicine, they must be
obtained from an official outlet and NOT from ward stocks
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ASEPTIC DISPENSING AND MANUFACTURING
Pharmacy provides an aseptic dispensing and manufacturing service for intravenous
medicines. All preparation of cytotoxic chemotherapy and TPN within the Trust will be
made by the Pharmacy Aseptic Unit. Other intravenous products are prepared within the
Unit such as intravenous antibiotics and biologic products such as monoclonal antibodies.
The Unit is strictly regulated and is inspected annually by Quality Control North West. The
Unit is MHRA-licensed for manufacture of unlicensed special intravenous products and is
inspected by the MHRA.
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24. HOMECARE DELIVERY OF MEDICINES
Homecare delivery of medicines involves a third party ‘homecare’ pharmacy dispensing
hospital prescriptions and delivering dispensed medicines directly to the patients.
Homecare delivery is particularly suitable for repeat supplies of long-term, high-cost
specialist medicines. This removed the need for patients having to come to hospital to
collect prescriptions and await them being dispensed by the hospital pharmacy. The
ongoing care, monitoring and review of the patients remains the responsibility of the
relevant hospital specialist.
The Trust only uses homecare delivery suppliers as follows:
 Suppliers designated as the sole homecare supplier by the drug manufacturer or
 Suppliers who are listed in the NW Homecare Delivery Contract Framework
Before use of a particular ‘approved’ supplier for the first time for a specific medicine,
Pharmacy and the consultant specialist will confirm that the supplier can meet the Trust’s
requirements to ensure safe and timely supply of medicines to our patients. This may
require the provision of sharps boxes, collection and safe disposal of sharps. The details of
the service which will be provided will be summarised in a Service Level Agreement (SLA)
which will be signed by representatives of Pharmacy and the homecare delivery supplier.
Patients will be offered the choice of supply of their medicines by homecare delivery or by
the hospital pharmacy. All patients will be provided with an information leaflet explaining
homecare delivery, along with explanation of the service before a decision is made.
Patients are not obliged to agree to homecare delivery. Patients may opt out of homecare
delivery at any time by communicating their wishes to their consultant specialist or
pharmacy.
Once a patient has opted to receive homecare delivery of their medicines they will be
registered with the relevant homecare delivery supplier. A patient registration form will be
completed. One copy will be provided to Pharmacy and one copy will be kept in the
patient’s medical records.
The specialist will provide a prescription for the required medicine(s) to Pharmacy. A
pharmacist will clinically check the accuracy of the prescription to the same standard as for
hospital-dispensed prescriptions. If the prescription is correct and safe to dispense it will
then be posted to the homecare delivery supplier.
The homecare delivery company will then contact the patient to confirm arrangements such
as contact details, delivery dates, times for delivery etc.
The pharmacy of the homecare delivery supplier will then dispense the medicines to the
standards specified in the contract and also the General Pharmaceutical Council and CQC.
Delivery of the medicines to the patient will then be arranged and carried out.
Confirmation of delivery and details of each supply made will be provided to the hospital
pharmacy. Pharmacy will then check that the details are correct and record the supplies in
the Pharmacy JAC system.
All problems relating to homecare delivery of medicines such as failure to deliver as
arranged will be recorded as incidents on Datix and monitored. Feedback on supplier
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performance will be provided to the supplying company, the lead for the NW homecare
contract framework (curently SBS), the NW technical services pharmacist for procurement
and the drug manufacturer if appropriate (eg. when the manufacturer specifies a sole
homecare supplier).
Homecare delivery will be co-ordinated and managed within Pharmacy by the Pharmacy
Procurement Team.
The Trust is committed to developing the management of homecare delivery to implement
the recommendations of national guidance on homecare delivery.
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25. PATIENTS OWN DRUGS (PODs)
Patients own drugs may be used for inpatients and on discharge in accordance with the
algorithm below. PODs may only be used for the patients named on the labels.
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26. STORAGE OF MEDICINES
The Trust SOP for the Safe Storage & Security of Medicines contains both policy
requirements and detailed advice. This SOP replaces the section on medicines storage
and security which was in previous editions of the Medicines Policy.
Click this link to access the SOP via Medicines Resources Intranet site
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27. ADMINISTRATION OF MEDICINES
The Medicines Resources Intranet site provides a detailed section on medicines
administration. This lists the Trust SOPs for administration of different types of medicines,
providing both policy requirements and detailed procedural instructions.
The NMC provides standards for medicines management, including administration of
medicines. These are supported by the Trust.
The SOP for ‘General Principles of Medicines Administration’ underpins all of the SOPs.
Please click this link to go the Medicines Resources Intranet site section on Medicines
Administration
Action if there is any concern about a prescription before administration
If there is any doubt about the clarity, accuracy, appropriateness or legality of a prescription,
or if the registered practitioner does not understand the prescription, he/she must consult
the prescriber and ask for clarification. The prescriber or on-call doctor must re-write the
prescription or administer the medicine personally. If the prescriber refuses to re-write the
prescription, the registered practitioner must not administer the dose but should contact his
or her manager, or a more senior member of medical staff.
Medicines optimisation – understanding the patient’s experience
Up to 50% of patients do not take their medicines as recommended. To ensure the best
possible outcome from medicines, there must be an ongoing, open dialogue with the patient
and/or their carer(s) about the patient’s choice and experience of using medicines to
manage their condition. It must be recognised that a patient’s experience may change over
time even if their medicines do not.
Controlled drugs (CDs) – follow this link
Cytotoxic chemotherapy – follow this link
Blood products – are not covered by the Medicines Policy
Epidural & spinal injections & infusions are high risk routes and may only be
administered by individuals who have undergone specific training and demonstrated
competence.
Click to go back to main contents table
NON-WRITTEN PRESCRIPTIONS
No medication should be normally administered to a patient in the absence of a valid
written prescription. There are currently some exceptions:
Emergency Situations
 In situations of extreme urgency a qualified registered practitioner may accept verbal
prescriptions BUT NOT FOR CONTROLLED DRUGS, INSULIN OR IV
POTASSIUM.
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The doctor should undertake to sign the entry on the drug prescription sheet within
12 hours.
Signatures still required at the end of the period of duty must be highlighted at shift
handover, signatures outstanding after 12 hours must be notified to the Matron
In an emergency situation when drugs are given by the Doctor or by a registered
practitioner in the presence of a Doctor without written prescriptions, the registered
practitioner preparing the drug must show the labelled container to the doctor before
the drug is administered. This will enable them to reaffirm the verbal prescription
and avoid the possibility of mistakes being made.
The initials of the person administering the drug and witness must be recorded in the
administration section of the prescription also.
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Verbal Prescriptions By Telephone
The following must be adhered to:
 The prescribing Doctor clearly spells out the name of the drug, the dosage and the
times to be given. This should be repeated back to the Doctor by the registered
practitioner.
 In the interests of both parties, wherever possible, the Doctor should repeat the
message to a second person acting as a witness. It is appreciated however, that
this cannot happen when the registered practitioner is alone.
 In the event of a Doctor refusing to comply with the above procedure, nurses,
midwives and ODP’s are advised to refuse to administer the drug.
 The nurse/midwife/ODP will enter the details of the drug on the drug prescription
sheet, indicating the time of the telephone call
Patient Group Directions (PGDs)
Click this link to go to the section on PGDs
Homely remedies

At the time of writing this Policy a PGD for nurse/midwife administration of homely
remedies without a prescription is under development. Homely remedies include
medicines such as paracetamol, senna, lactulose, chlopheniramine.

An authorised Trust prescriber must prescribe all doses of these medicines unless a
relevant PGD is applicable.
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USE OF PATIENTS’ OWN DRUGS (PODs)
Patients’ own medications may be used for inpatients only if of suitable quality for use and
for the individual named patient only. Whenever possible PODs will be checked by
Pharmacy staff for suitability. However, outside of Pharmacy hours, to avoid delaying or
missing a dose, nurses may assess PODs and if suitable for use, administer a dose.
Click this link to go to the checklist for suitability of PODs for use
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SELF-ADMINISTRATION OF MEDICINES

Supervised self-administration. On all wards & departments, registered
practitioners may supervise the self-administration of a medicine by a patient whilst
maintaining responsibility for the safe storage and safe administration of the medicine.
The registered practitioner is responsible for assessing the patient’s capability for
supervised self-administration. The patient’s ability may change over time, therefore
reassessment must be undertaken regularly. Knowledge of a patient’s ability to
correctly administer medicines without supervision at home is particularly important
prior to discharge from hospital. Supervised self-administration is particularly useful
prior to discharge and may accompany training on the correct use of medicines.
Common examples of medicines which are suitable for supervised self-administration
and which may require training include inhalers, creams, eye drops, pre-filled insulin
pens.

Security of self-administered medicines. Ward staff must ensure the security of
medicines being self-administered by patients. These should normally be stored in the
locked bedside medicines lockers or the CD cupboard or fridge if appropriate.

Rescue medicines. Patients may keep rescue medicines such as salbutamol
inhalers and GTN sprays at the bedside when appropriate. The ability to competently
self-administer these medicines must be confirmed. These patients must be instructed
to advise the nursing staff of any use as soon as possible so that the administration
can be recorded on the medicines kardex.

Symptom-relief medicines (low risk). Patients may keep low risk medicines for ‘as
required’ symptom relief at the bedside if appropriate. Such medicines will include
artificial saliva, artificial tears, emollients & moisturisers, throat lozenges (eg. Strepsils).
The ability to competently self-administer these medicines must be confirmed. These
patients must be instructed to advise the nursing staff of any use so that the
administration can be recorded on the medicines kardex.

Independent self-medication. The Trust Policy for Self Administration of Medicines
gives detailed guidance on the management of independent self-administration where
patients may be given responsibility for the storage and administration of their
medicines. This Procedure is not in widespread use and the Deputy Director of
Nursing and Midwifery or the Head of Pharmacy should be contacted for further advice
by any wards/depts considering full patient self-administration. This Policy is included
as Appendix 1 at the end of this Policy.

Non-approved self-administration. The concealed and non-approved
administration of medicines to patients by themselves or by relations or visitors is
highly dangerous. This includes any medicine which is administered without the
knowledge of nursing or clinical staff. Any such incidents must be reported to the ward
manager or lead clinician immediately. Details of the medicines administered must be
sought and a member of medical staff must be informed. Other action should be
determined according to the circumstances and medicines involved. The incident must
be documented in the medical notes and reported on Datix.
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COVERT ADMINISTRATION OF MEDICINES
Guidance on Trust policy is available regarding administration of medicines to adult patients
who refuse medicines and who are judged to lack the capacity to give consent. Click here
to go to the Covert Medicines Guidance.
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ADMINISTRATION OF CYTOTOXIC CHEMOTHERAPY

Vinca alkaloids. Click here to access the policy which includes requirements for
administration

Oral anticancer medicines. Click here to access the policy which includes
requirements for administration

IntraTHECAL chemotherapy. A separate policy exists for intrathecal chemotherapy

Authorisation to administer cytotoxic chemotherapy.
 Cancer chemotherapy can only be administered by authorised medical and
nursing staff.
 Medical staff must be authorised by the supervising consultant who is
experienced in the administration of cytotoxic chemotherapy after receiving
specific training.
 Registered nurses must have successfully attended a post registration IV study
day and have undergone training and assessment in intravenous and/or other
routes of cytotoxic drug administration.

The Trust follows Merseyside & Cheshire Cancer Network procedures & guidelines for
administration and management of cancer chemotherapy. This information is available
via the internet and within folders held on Ward 2a and in the Lilac Centre. This
information includes action required for extravasation.
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TAKE HOME MEDICATIONS (TTOS) – SUPPLY TO PATIENTS ON WARDS


Take home medications will normally be explained and handed over to patients on
wards by nursing or midwifery staff in accordance with Trust Policy for Discharging
Patients.
Nurses must never dispense from ward stocks for patients going home as this is
specifically prohibited within the terms of the Medicines Act (1968). Some wards
have designated pre-dispensed, ready-labelled medicines suitable for supplying
outside of Pharmacy hours in accordance with an SOP for this purpose.
Arranging for Pharmacy to supply TTO medicines
 Careful discharge planning should ensure sufficient time for for TTOs to be
dispensed and returned to the ward so as not to delay discharge.
 The take home prescription must be written on ICE discharge and approved by the
prescriber. Whenever possible, the ward staff should liaise closely with their ward
pharmacy team to arrange for the TTO prescription to be checked on the ward.
 If it is not possible for pharmacy staff to check the TTOs on the ward within a suitable
timescale, the TTO must be sent to Pharmacy along with the inpatient prescription
kardexes, patients own drugs (PODs) and any individually labelled medicines such
as inhalers, creams, eye drops etc.
Receipt of dispensed TTO medicines on wards.
 All take home medication should be checked against the TTO prescription by a
Registered Nurse/Midwife, upon arrival on the ward from Pharmacy.
 An entry must be made in the patient’s case sheet stating that the medication is
correct, dated and signed by the checking nurse.
 All take home medication must then be stored in a locked drug cupboard specifically
identified for this purpose, until the patient is discharged
Upon discharge.
 All take home medication must be checked by a registered nurse/midwife together
with the patient/relative (where appropriate) just before the patient leaves the ward.
 An entry must be made in the patient’s case sheet stating that the medication is
correct, dated & signed by the Nurse and the patient/relative
 Where the patient/relative is unable or refuses to sign the case sheet, the check
must be made by two nurses who must both sign the case sheet.
 The registered nurse/midwife must always be satisfied of the correct identity of the
patient before handing over medicines.
 When a patient has already left the ward, a relation or other person may return to the
ward to collect the take-home medicines. Ward staff must be assured of the identity
and authority of the person presenting for collection prior to handing medicines over.
TTOs with controlled drugs (CDs)
 Nursing staff must follow the process described in the Trust SOPs for Controlled
Drugs
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28. MISCELLANEOUS
DRUG INCIDENTS
Drug incidents may include prescribing, supply or administration errors, loss or wastage of a
drug, or product faults.
Drug incidents will be managed in accordance with the Trust Incident Reporting and
Management Policy.
For drug administration incidents, brief medicines-specific guidance on use of the Trust
Incident Reporting & Management Policy is provided in the SOP for Administration of
Medicines – General Principles
If a drug incident occurs then the following people must be informed immediately:
 The ward/dept manager or nurse in charge of the ward or department

The doctor concerned if inappropriate administration of a drug has occurred

The matron or site manager, if out of hours

A pharmacist, if the incident involves loss of a drug

A pharmacist for advice on drug effects and management if administered
An Datix report must be completed
Incidents, including those involving drugs will be reviewed at Care Group Governance
meetings, Trust Medicines Safety Group and the Patient safety Council on a regular basis.
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DRUG DEFECT REPORTING


All Hospitals are required to comply with strict procedures for the notification of defects
found in medicinal products. Anyone becoming aware of a defective medicine should
contact a pharmacist without delay (out of hours - contact the on-call pharmacist). This
will enable the pharmacist to institute a local recall of that batch and notify the
Department of Health so that a warning can be cascaded throughout the NHS.
Alerts giving warnings about the safety of medicines may be received from a number of
sources including the MHRA, CSM, NPSA, local alerts. The Pharmacy is a member of
a National cascade system which makes provision for in-hours and out-of-hours alerts.
Upon receipt of a new alert Pharmacy staff will follow departmental procedure. Briefly,
this requires an assessment of the relevance of the alert to the Trust. Cascade of
information within the Trust and/or recall of affected products will be conducted as
appropriate and within timescales specified within the alerts. If the alert relates to
treatment which patients of the Trust have received, the relevant clinical directors and
consultants will be notified immediately. Documentation will be completed and retained
in the Medicines Information section of Pharmacy.
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ADVERSE DRUG REACTION REPORTING
All staff with involved with medicines (doctors, registered practitioners and pharmacists) are
strongly urged to report or to prompt the submission of a report of any suspected adverse
drug reaction (ADR). If in doubt, or unsure of procedure, please seek the advice of a ward
pharmacist or Pharmacy Medicines Information on ext 1565. The British National
Formulary (BNF) provides advice about reporting ADRs.
What to Report
New drugs (marked in the BNF with an inverted black triangle)
 Report all suspected reactions, however minor, which could be attributed to the drug.
 The reaction should be reported even if well-recognised or if you are unsure of the
causal relationship
Established drugs
 Report serious suspected reactions, including fatal, life threatening, disabling or
incapacitating events
 Report a serious reaction even if it is already well recognised
 Do not report minor reactions for established drugs
 Report all reactions, including minor ones, for children aged under 18 years.
How to Report
Yellow cards for reporting ADRs to the CSM are available
 In the BNF
 Via the Trust Medicines Resources Intranet site page on Adverse Drug Reactions
 On the internet at www.yellowcard.gov.uk
When completing the form, please give details, if possible of brand name and batch
number. This is particularly important for:
 Over the counter drugs
 Slow or delayed-release formulations
 Vaccines
 Biotechnology products eg. Human growth hormone
Where to Report
Completed hard-copy forms should be sent to the Committee on Safety of Medicines (CSM)
via the Pharmacy Medicines Information.
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SUSPECTED THEFT OR FRAUDULENT PROCUREMENT OF MEDICINES
In some circumstances there may not be enough evidence to determine if an incident has
occurred or not. An example is if the usage of a drug on a ward increases without obvious
explanation relating to clinical activity. Some drugs have been implicated in theft and abuse
more than others. In particular staff should be vigilant for unexplained usage of the
following:
 Codeine
 Co-codamol
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Co-dydramol
Dihydrocodeine
All benzodiazepines eg. diazepam, nitrazepam, lorazepam, midazolam
Zopiclone, zolpidem and zaleplon
Cyclizine
Nicotine replacement treatment
Weight loss products
Impotence treatments
Drugs with potential for abuse in sport or bodybuilding
Theft and fraudulent procurement can occur from ward stocks, non-stock medicines and
patient’s own medicines.
If theft of fraudulent procurement of medicines is suspected, this must be reported
immediately to a matron/Dept Manager, Deputy Director of Nursing, the Head of Pharmacy
(or deputy), clinical director. The Trust’s Local Counter Fraud Specialist, NHS Protect Local
Security Management Specialist and the Police may be contacted to advise and to
investigate.
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LIQUID NITROGEN
Liquid nitrogen is a cryogenic liquid gas which is used in cryotherapy performed within
Dermatology clinics. It is stored in specialised storage flasks in purpose-designed stores
which have good ventilation. At Whiston Hospital it may only be dispensed by specifically
trained pharmacy or portering staff. At St Helens Hospital it may only be dispensed by
specifically trained pharmacy, portering or nursing staff. Dispensing of liquid nitrogen will
be in accordance with a specific SOP. Flasks containing liquid nitrogen must never be
transported in a lift or stored in a confined space due to the risk of asphyxiation.
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DISPOSAL OF UNNEEDED & EXPIRED MEDICINES AND WASTE




Empty medicines boxes should be disposed of in accordance with the Trust’s Waste
Management Policy & Guidelines. Folders providing instruction on waste management
are available in all clinical areas.
Patient identifiable labels must be removed before disposing of empty medicines
containers in the black waste bags. These labels must be disposed of in accordance
with procedures for disposing of other patient-identifiable confidential waste.
Part-administered doses of injections of infusions in clinical areas should be disposed of
using the appropriate sharps disposal bins. Gel Vac sachets are available to absorb
liquid medicines within sharps bins in order to reduce the risk of splashes and render
any drug residue unusable.
All packs of medicines which are no longer required, including non-stock medicines,
patients’ own drugs, expired medicines must be placed in a Pharmacy Returns bin
(Glasdon Bin) if available or otherwise securely stored in the clinical area before
returning securely to Pharmacy for processing. Details are provided in the Trust SOP
for Safe Storage and Security of Medicines.
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Pharmacy does not re-use plastic or glass bottles. Empty glass bottles should be
disposed of in the glass bins provided.
All unusable medicines, including all patients own drugs are processed in accordance
with Pharmacy procedures for handling waste.
Leeches and maggots are disposed of as per 5.7.
Returns to Pharmacy are detailed in the SOP for Safe Storage and Security of
Medicines
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LEECHES AND MAGGOTS
Biotherapy with leeches and maggots is conducted within the Trust. Therapy must be
prescribed as for the generic standards detailed for other drugs. SOPs are available which
provide detailed guidance upon their supply, use and disposal. Guidance on their use is
available from Pharmacy and clinical staff who are experienced in their use. Maggots and
leeches may only be used once in a named patient. After use they are killed in accordance
with the relevant SOP. The subsequent waste is disposed of as per the Infection Control
Policy guidance for infectious waste. They are double bagged in yellow clinical waste bags.
The waste management team are then contacted, who will arrange for collection and
destruction by incineration.
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MEDICAL GASES
Medical gases including oxygen, medical air and nitrous oxide are licensed medicines. The
storage, transport and maintenance of equipment relating to medical gases is managed on
behalf of the Trust by Vinci FM and overseen through the Trust Medical Gases Committee.
Testing of the medical gas storage and distribution system (piping) is contracted on the
Trust’s behalf to Pharmaceutical Quality Control North West (QCNW). The clinical
management of medical gases is managed by the Trust’s Oxygen Steering Group. The
clinical use of oxygen and medical air is covered by the Trust SOP for Management of
Medical Gases, Oxygen and Medical Air.
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MEDICINES-RELATED POLICIES, PROCEDURES, PROTOCOLS AND GUIDELINES
Medicines-related policies, procedures, protocols and guidelines should be approved by the
Trust’s Drug and Therapeutics Group or Medicines Safety Group before implementation.
Documents must comply with the standards specified in the relevant Trust policy for
document control where appropriate. Before producing such documents, staff are advised
to consult a pharmacist who will then provide guidance or will refer on to an appropriate
colleague.
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Medicines Policy (June 2015)
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29. PROCESS FOR IMPLEMENTING THE MEDICINES POLICY
The Medicines Policy and subsequent updates will be implemented by the following:
 Trust Team Brief
 Global e-mail to all staff following approval of new version
 Publication on the Trust Intranet including the Medicines Resources Intranet Site
 Inclusion in Trust induction for all new clinical staff
 Inclusion in Mandatory Training on Medicines for all clinical staff
 Inclusion in the foundation stage junior doctors teaching curriculum including an
extended induction session
 Medicines management link nurses
 Updates to ward and clinical areas presented by pharmacists on an ongoing basis as
requested or required
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30. EDUCATION AND TRAINING

Training required to fulfil this Policy will be provided in accordance with the Trust’s
Induction Mandatory and Risk Management Training Policy – Training Needs Analysis.

The Policy and key messages are included within the Trust Mandatory Training on
Medicines Optimisation which is provided to all clinical staff.

The Medicines Policy and key medicines management messages are highlighted to all
new Trust clinical staff at Trust induction.

Detailed aspects of prescribing, including the Medicines Policy are included in the
foundation stage doctors induction programme and their curriculum for education on
prescribing.

Training for nursing staff with specific medicines components includes the Trust’s
intravenous administration course and preceptor nurse study days.
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31. MONITORING OF THIS POLICY
Monitoring of compliance with this Policy will be overseen by the Clinical Effectiveness
Council
Key Performance Indicators of this Policy
Process for prescribing and accuracy of
Annual review
prescriptions
Mandatory Training
Monthly
Medicines-related incidents
Quarterly
Head of Pharmacy
Assistant Director of
HR
Head of Pharmacy
Aspect of
compliance or
effectiveness
being monitored
Monitoring
method
Individual
responsibl
e for the
monitoring
Frequency of
the monitoring
activity
Group /
committee
which will
receive the
findings/mo
nitoring
report
Scheduled
pharmacist visits
to wards
a) Annual
standards of
prescribing
review
b) Pharmacist
intervention
monitoring
Pharmacist
s
Daily or as
scheduled
b
Process for
prescribing
medicines
Process for
ensuring the
accuracy of all
prescription charts.
Pharmacy
a) Annual
b) Annual
Clinical
Effectiveness
Council
Clinical
Effectiveness
Council
c
Mandatory training
Monitoring of
ESR and Trust
performance
management
reports
Monthly
HR Council
d
Medicines-related
incidents
Review of
incidents
reported on
Datix
Assistant
Director of
HR
(Organisati
onal
Developme
nt)
Principal
Pharmacist
Quarterly
Patient
Safety
Council
a
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Group /
committee /
individual
responsible
for
ensuring
that the
actions are
completed
Medicines
Safety
Group
Medicines
Safety
Group
32. COUNTER FRAUD STATEMENT
Staff are reminded that to make a fraudulent claim is, potentially, a criminal offence as well
as being contrary to Trust policies. Contacting your Local Counter Fraud Specialist (LCFS)
with any concerns will not breach the Data Protection Act as section 29 (3) of the Act allows
for the release of information for the ‘prevention and detection of crime’. Your Local Counter
Fraud Specialist can be contacted on 0161 206 8162. Alternatively, information can be
given to the confidential NHS Fraud and Corruption Reporting Line (FCRL) by phoning
0800 0284060. The FCRL is a Freephone number and a simple means of reporting
concerns about NHS fraud. It allows NHS staff who are unsure of internal reporting
procedures or who wish to speak with complete confidentiality to report their concerns. All
calls are dealt with by experienced, trained staff and callers may remain anonymous if they
wish. You can also report online at www.reportnhsfraud.nhs.uk.
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33. REFERENCES / BIBLIOGRAPHY

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The Medicines Act 1968 and subsequent amendments
The Misuse of Drugs Act 1971 and subsequent amendments
The Safe and Secure Handling of Medicines – A Team Approach (RPSGB 2005)
Good practice in prescribing medicines – guidance for doctors (GMC 2013)
Standards of conduct, performance and ethics for nurses and midwives (NMC 2008)
Standards for Medicines Management (NMC 2010)
Medicines, ethics and practice – a guide for pharmacists (RPSGB 2014)
British National Formulary (Sept 2014)
BNF for Children 2014-15
The Best Medicine: The Management of Medicines in Acute and Specialist Trusts (HCC
2007)
NHSLA Risk Management Standards for NHS Trusts providing Acute, Community or
mental Health & learning Services and Independent Sector Providers of NHS Care
CQC Guidance for providers on meeting the regulations (March 2015)
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34. POLICY HISTORY
VDate
Version
Author
Designation
Head of
Pharmacy
Head of
Pharmacy
Summary of key changes
 Added in requirement to report when no planned ward pharmacist visit
can be provided
 Updated pharmacist checking and endorsement details to correspond
with new kardexes
 Removed obsolete references to ‘yellow label’ supplies
1.2.08
2
9.6.11
3
1.3.12
3.01
Head of
Pharmacy
25.11.13
3.02
Head of
Pharmacy
 Update of previous Policy
 Complete revision of the Policy to reflect NHSLA, Standard 4, Criterion
5 requirements: The NHSLA Risk Management Standards for NHS
Trusts providing Acute, Community or mental Health & learning
Services and Independent Sector Providers of NHS Care
 Replacement of the term ‘nurse/midwife’ with ‘registered practitioner’ to
recognise that ODPs now have legal status in medicines management
processes.
 Incorporation of stronger counter fraud statements
 Inclusion of the Policy for Self-medication as an appendix rather than a
stand-alone policy
 Inclusion of ‘Standards of Prescribing’ assessment tools for prescription
accuracy as appendices
 Amend discrepancy between Policy and SOP for intravenous drug
administration – section 4.4.3, page 45
18.3.14
3.03
Head of
Pharmacy
 Extension of review date recommended by Drug & Therapeutics
Committee and approved by Clinical Effectiveness Council
 Updates relating to medicines security and administration of medicines
to ensure consistency between policy and relevant Trust SOPs
 Additional contents section added to aid location of medicines security
information
 Update relating to GMC guidance on prescribing for persons with
whom there is a close personal relationship
 Reference to ICE electronic discharge prescriptions
24.10.14
3.04
Head of
Pharmacy
 Extension to review date recommended by Drug & Therapeutics Group
 Signposting to the Medicines Resources intranet site added throughout
the Policy
 Change of name of Drug & Therapeutics Committee to Drug &
Therapeutics Group (DTC to DTG)
 Reference to Medicines Safety Group (MSG)
 Reference to electronic prescribing implementation in 2015
17.6.15
4
Head of
Pharmacy




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Reformatting in line with revised Trust document control policy
Hyperlinked contents to aid navigation
Use of hyperlinks to web-sites and intranet locations
Reduced overlap with other Trust policies & procedures and risk of
non-alignment eg. storage & security, medicines administration
 Cite Medicines Optimisation Strategy
 Active references to Medicines Resources Intranet site
 Enabling statements for ePMA
 Incorporation of Non-Medical Prescribing Policy
 Incorporation of Medicines Reconciliation Policy
 New sections on information sources, NICE, homecare delivery,
antimicrobials, OPAT, patients own drugs, clinical trials
Medicines Policy (June 2015)
Current version is held on the Policy section of the Intranet


Updates to sections on unlicensed medicines, transcribing, selfmedication, cytotoxics, TTOs
References to NHS Protect LSMS in addition to Counterfraud Service
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35. EQUALITY ANALYSIS
Equality Analysis Stage 1 Screening
1
Title of Policy:
2
Policy Author(s):
3
Lead Executive:
4
Policy Sponsor
5
Target Audience
6
Document Purpose:
7
Please state how the policy is relevant to the
Trusts general equality duties to:
 eliminate discrimination
 advance equality of opportunity
 foster good relations
This is an operational Trust policy which
does not have direct relevance to Trust
equality duties
8
List key groups involved or to be involved in
policy development (e.g. staff side reps, service
users, partner agencies) and how these groups
will be engaged
This Policy is a revision. Consultation has
been held with suitably qualified members
of staff including members of the Drug and
Therapeutics Committee, Pharmacy, MIAA
Local Counter Fraud Specialist.
Organisation-wide Medicines Policy
Simon Gelder, Head of Pharmacy
Dr Kevin Hardy, Medical Director
Dr Kevin Hardy, Medical Director
All Trust staff involved with the prescribing,
supply, administration and handling of
medicines
 Define the Trust-approved practices
relating to the safe and secure handling
of medicines for all staff involved in the
handling and use of medicines.
 Minimise and control the risks to
patients, the staff and the organisation
associated with medicines
NB Having read the guidance notes provided when assessing the questions below you must
consider;
 Be very conscious of any indirect or unintentional outcomes of a potentially discriminatory
nature
 Will the policy create any problems or barriers to any protected group?
 Will any protected group be excluded because of the policy?
 Will the policy have a negative impact on community relations?
If in any doubt please consult with the Patient and Workforce Equality Lead
9
Does the policy significantly affect one group less or more favorably than another on the
basis of: answer ‘Yes/No’ (please add any qualification or explanation to your answer
particularly if you answer yes)
Yes/No
.

Race/ethnicity


Disability (includes Learning Disability,
physical or mental disability and sensory
impairment)
Gender

Religion/belief (including non-belief)

Sexual orientation

Age
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Comments/ Rationale
No
No
No
No
No
No
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
Gender reassignment

Pregnancy and Maternity

Marriage and Civil partnership

No
No
No
Carer status
No
10
Will the policy affect the Human Rights of any of
the above-protected groups?
No
11
If you have identified potential discrimination,
are there any exceptions valid, legal and/or
justifiable?
N/A
12
If you have identified a negative impact on any
of the above-protected groups, can the impact
be avoided or reduced by taking different
action?
N/A
13
How will the effect of the policy be reviewed
after implementation?
The Policy will be audited at least annually
in line with key performance indicators
If you have entered yes in any of the above boxes you must contact the Patient and Workforce
Equality Lead (ext 7609/ Annette.craghill@sthk.nhs.uk) to discuss the outcome and ascertain
whether a Stage 2 Equality Analysis Assessment must be completed.
Name of manager completing assessment:
(must one of the authors)
Job Title of Manager completing assessment
Simon Gelder
Head of Pharmacy
Date of Completion:
6.5.15
The Trust has a duty as a public body to publish all completed Equality Analysis Screening and
Assessments. Please forward a copy of your completed proforma to Annette.craghill@sthk.nhs.uk
The Patient and Workforce Equality Lead will conduct an audit on all completed Screening and
Assessments every six months.
Click to go back to main contents table
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36. APPENDICES
Appendices follow on the next pages
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Appendix 1
SELF MEDICATION POLICY
INDEX
Section and Contents
Page
Introduction
3
Education and training
3
Procedure for self-medication
4
Supply and storage of medication
7
Drug administration errors
8
Discharge procedure
9
Audit and review
9
Appendices
1.
Patient consent for self-medication
10
2.
Algorithm for the assessment of patients’ ability to self-medicate
11
3.
Patient information leaflet
14
4.
Medication reminder chart
16
DEFINITION OF TERMS
Self-Medication is the term used to describe the process whereby patients administer their own
medication under various levels of supervision by qualified nursing staff.
Compliance in medicine taking can be defined as the patient taking a dose at exactly the correct time
and in exactly the correct way.
Concordance is an agreement between a patient and a healthcare professional that respects the
beliefs and wishes of a patient in determining whether, when and how medicines are taken.
Nurse – within this Policy, the term nurse refers to both registered nurses and registered midwives
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1.
INTRODUCTION
Scope and Implementation
1.1
This Policy is a developmental Policy. It is only for use on wards/departments which have been
approved by the Trust to implement this Policy, and also those which plan to gain approval in future.
Approval to implement this Policy upon a ward or department must be gained from all of the following:
 Director of Nursing & Midwifery
 Clinical Director for the relevant directorate
 Head of Pharmacy
Wards which are not approved to implement this Policy must continue to follow the standards for
administration detailed in the Trust Medicines Policy and the Clinical Policies, Procedures, Protocols
& Guidelines. Provision for supervised self-administration of medicines is provided.
1.2
Aims



1.3
Objectives







2.
To implement National policy which supports the wider implementation of patient self-medication.
To assess and improve patients understanding of their medication in order to improve
concordance and compliance with their medication regime
To enable the Trust to fulfil its requirement to have a robust process for patient self-administration
whilst maintaining the safe and secure handling of medicines
To ensure that patients can take their medication correctly during their hospital stay in preparation
for discharge.
To identify those patients who need further assistance with their medication in order to improve
their compliance. This could be for example in the form of a compliance aid or in the provision of
education and information about their medication.
To allow patients experiencing problems to practice taking their medication under supervision.
To return custody and control of medication to the patient, thereby promoting involvement,
improving morale and empowering patients to achieve/maintain a greater degree of
independence during their stay.
To allow medication to be taken at more appropriate times rather than fixed to nurse drug rounds
e.g. pain relief can be taken when required and medication taken on a full or empty stomach
where indicated.
To promote a multi-disciplinary approach to the management of patients’ medication.
To implement the professional standards and guidance on patient self-administration detailed in
the NMC document ‘Standards for Medicines Management’ 2007.
EDUCATION AND TRAINING
Nursing and medical staff working on a ward participating in self-medication must read this
Policy and sign to confirm that they have both read and understood the policy. A copy of the
self-medication policy and the list of staff signatures will be kept in a file on each participating
ward.
Pharmacists, one stop technicians and all nursing staff involved in self-medication should
also attend an in-house training session conducted by the Pharmacy department. Bank staff
will not be routinely trained unless they regularly work on a participating ward. They should
ask for assistance from staff trained in self-medication when conducting medication rounds.
3.
3.1
PROCEDURE FOR SELF-MEDICATION
Consent
All patients who participate in self-administration of medication must give their consent to participate.
Patients should be informed that participation is entirely voluntary and if they decide to ‘opt out’ their
care will not be affected in any manner.
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After being assessed as competent to self-administer medicines the patient will be asked to sign their
consent to inclusion in the scheme. The signed consent must be stored in the medical notes (see
Appendix 1).
3.2
Assessment
All patients will be assessed by appropriately trained nursing staff, as to their ability to self-medicate whilst in
hospital. The Algorithm (see Appendix 2) will be used for this purpose. This nurse will also be
responsible for explaining the self-medication scheme to the patient, providing the patient with an
explanatory information leaflet (see Appendix 3) and obtaining their signed consent (see Appendix 1).
If the patient is deemed unfit to self-medicate, formal assessment will be delayed until such time that the
patient’s condition improves. This should be documented on the assessment form.
3.2.1
Levels of self-medication
Levels of
self-medication
1
2
3
Description
Not self-medicating
Self-medicating under Nurse supervision
Self-medicating independently
The registered nurse responsible for the patient will assign the patient to one of three levels of selfmedication depending upon their assessment. Patients may then move through the level, up or down,
as their condition, confidence and competence allow. If a patient’s ability to self-administer their
medication changes, this must be recorded on the results of assessment form (Appendix 2).
Patient safety is of paramount importance and caution should be applied at all times. Where a
patient’s competency is unclear, or in situations where a patient is assessed as ‘at risk’ of deliberate
or accidental overdose, they will be assessed as level 1 (Note exclusion criteria section 4.6).
Level 1
Not self-medicating
The nursing staff will administer the medication from the patient’s medication cabinet
The nurse administering the medication initials the inpatient prescription chart.
Level 2
Self-medicating under nurse supervision
The nursing staff open the patient’s medication cabinet at the appropriate times. The patient
administers the medication with nurse supervision, using the medication reminder chart (Appendix 4)
as a prompt.
The nurse will be able to assess the patients understanding of their medication and of the process of
medicines administration. Also they will be able to observe the patient’s physical ability to read and
understand labelling instructions and their ability to open packaging (Any difficulties should be
reported to the ward pharmacist).
The nurse initials the inpatient prescription chart.
NB: The master key should be used to open the cabinet for patients on levels 1 and 2. The
individual cabinet key must remain stored in a suitable locked cupboard and not issued to the
patient.
Level 3
Self-medicating
An initial period of supervision at level 2 should occur until the trained nurse is satisfied that the
patient is competent.
The patient can then move to level 3. The patient is issued with a key to their individual medication
cabinet and the patient administers his or her own medication without direct supervision. The patient
will be given a medication information chart to aid them.
The nurse should check the in-patient prescription chart for any changes 4 times a day and cross
reference this with the medication information chart and update this where necessary.
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The nurse initials the in-patient prescription chart with the self-medication code daily after confirming
self-medication with the patient and also signs their own initials.
Medical staff must inform patients who self-medicate when they make a change to their prescription.
They should also inform the nurse looking after the patient who should stop the patient selfmedicating until new medication is supplied or existing medication re-labelled. It is the nurse looking
after the patient who is responsible for removing discontinued medication from the patient’s
medication cabinet. The patient must then be re-educated on the changes by the nursing staff and the
medicine information chart updated before self-medication can re-commence.
The pharmacy staff will complete a twice weekly tablet count of the patient’s medication to ensure
compliance. The result of which will be documented on the nursing assessment documentation. (See
Appendix 2).
3.4
Key responsibilities
Key responsibilities




Nursing staff







Doctor
Pharmacist and
Pharmacy Technician










Patient
3.5
Understand and implement this Policy
Assess patient suitability to self-medicate
Patient support and education
Check medication chart for changes and remove discontinued
medication
Write and update medication information chart
Check administration with patient and initial in-patient prescription
chart
Documentation
Key and medicines security
Report all drug administration errors (see Section 5)
Participate in reviews and audits of this Policy
Inform nursing staff and patients of any changes made to medication
and amend the in-patient prescription chart
Review any patient where a drug administration error has occurred
Education and training to relevant hospital staff on self-medication
policy
Checking all medication is suitable for self-medication. Supplying
new and further supplies of medication
Patient education and supply of medicine information if necessary
Pharmacist to provide second check on the medication information
chart
Review of patients referred by nursing staff who may require
compliance aids
Investigating drug administration errors
Weekly tablet counts
Participate in reviews and audits of this Policy
Safe custody of individual locker key and medication
Checks and controls
Patients participating in self-medication must be assessed by the nurse each day for their ability to
continue, during the daily check the nurse must:
1. Check the in-patient prescription chart for changes and update the medication information chart
2. Assess if the patient’s ability to self-medicate at the same level has changed
3. Discuss the drug regime with the patient to confirm their understanding
4. Document result of the checks on the assessment form (Appendix 2)
3.6
Exclusion criteria
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In the following circumstances patients should be excluded from unsupervised self-medication (level
3): 



Patients with chronic confusion or dementia
Patients with a potential to self-harm
Patients with a history of alcohol or drug misuse
Patients not expected to be responsible for their own medication after discharge i.e. nursing
home patients
If there is any other reasons that the patient is thought to be unsuitable by medical, nursing or
pharmacy staff
If any other patients in the bay are likely to cause problems with key/drug custody
Patients who are unwell, medically unstable or requiring frequent changes to medication or
dose



NB: Depending on the nursing assessment it may be possible for some patients covered by the
above to enter Level 2 supervised self-medication.
3.7
Documentation
It is the responsibility of the nurse in charge of the patient to complete the in-patient medication
information chart. This must be checked and countersigned by the ward pharmacist before the
patient is entered onto level 2 or 3 of the scheme. It is the joint responsibility of the nurse and the
pharmacist to educate the patient. The pharmacist will provide the patient with medication patient
information leaflets if required.
If a patient is self medicating this must be documented on the in-patient prescription chart by the
nursing staff. This will state the level of self-medication and the date self-medication commenced.
4.
4.1
SUPPLY AND STORAGE OF MEDICATION
Cabinets
To participate in the self-medication scheme wards must be equipped with individual lockable
medication cabinets located by the patient’s bed. The patient’s medication will be stored in this
cabinet. Each cabinet will have an individual key and can also be opened with a master key. A small
supply of ward stock will continue to be held on the ward in drug cupboards or trolleys.
All staff must remain vigilant to ensure that medication is locked away and keys are stored out of
sight. It is the responsibility of the registered nurse to monitor the safe and secure handling of
medicines belonging to patients assessed at level 3 and recommend appropriate remedial action if
drug security is ascertained to be at risk.
4.2
Keys
Master keys will be held by the nursing staff on the ward and must be accounted for at the
beginning of each shift. One key will also be stored in the Pharmacy Department for use by
the pharmacist and pharmacy technician.
The patient will be responsible for the individual cabinet key whilst participating in level 3 of
self-medication. It is the responsibility of the nurse discharging the patient to retrieve the key
on discharge. Individual cabinet keys, when not in use, must be stored in a suitable locked
cupboard and must remain inaccessible to patients.
All efforts should be made to find lost keys. If a master key is lost, all cabinet locks will have to
be changed. If an individual cabinet key is lost, then only that lock need be changed.
4.3
Medication supply and changes
All medicines self-administered by patients must be presented and labelled in a form that provides all
the information necessary for the patient to self-medicate without risk of error. This is achieved by:

Re-use of patients own drugs if considered suitable (see below)
Individually dispensed items from Pharmacy
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A 28-day supply of medication (except for treatment courses i.e. antibiotics) will be ordered by the
pharmacist and pharmacy technician on the ward, which will then be supplied by the Pharmacy
department labelled with directions.
Repeat supplies will also be organised by the ward pharmacist or pharmacy technician.
Patient’s own medication or medication transferred with the patient from a different hospital must be
checked for suitability for re-use by the pharmacy technician prior to the patient starting on the selfmedication scheme. Nursing staff should refer to the guidance on the re-use of patients own drugs
(PODS) and transfer of medicines between wards found in the Trust Medicines Policy if outside of
Pharmacy hours. If the assessing nurse is satisfied with the medicines suitability, self-medication at
level 2 can commence but they should ensure the medication is checked by Pharmacy staff at their
next ward visit.
The patient should verbally consent for the re-use or destruction of their own medication and should
be given the leaflet ‘Using your own medicines during your hospital stay’ found in the Trust’s
Medicines Policy.
Ward stock should be used until a labelled supply for the patient is available, however, ward stock bottles
should never be left in the patient’s medication locker and patients must never self-medicate from
ward stock bottles.
Controlled drugs, once-only medication and injections/infusions are not covered by the scheme.
These should be administered by nursing staff as per normal procedure. (Insulin can however be
self-administered by patients where appropriate).
5.
DRUG ADMINISTRATION ERRORS
All drug administration errors must be reported promptly in accordance with the Trust Drug Incident
Procedure for Nursing Staff. Details of the incident must be reported promptly using an IR1 form.
The following people must be informed immediately:
 The nurse in charge of the ward
 The consultant responsible for the patient, or the most senior doctor accountable for the patient if
out of hours
 The ward pharmacist, or if out of hours, the on-call pharmacist for advice on possible adverse
effects and management
The patient must then be re-assessed for suitability to self-medicate.
6.
DISCHARGE PROCEDURE
Medication in the patient’s cabinet must be checked against the discharge prescription by the
ward pharmacist or pharmacy technician (after the pharmacist has clinically checked the
prescription) before they are issued to the patient. In the absence of a ward
pharmacist/technician during working hours the prescriptions (inpatient prescription chart and
discharge prescription), and the medication from the individual cabinets must be sent to the
Pharmacy Department to be checked. Outside Pharmacy hours when a discharge is required
urgently the nursing staff should refer to the procedure in the Trusts Medicines Policy.
The patient will be issued with at least two weeks supply of medication when appropriate.
It is the responsibility of the nursing staff to ensure the medication is explained to the patient prior to
discharge.
On discharge, the patient may be issued with a pink medication reminder chart (available from
Pharmacy) if required. This may be of use for patients or carers who have difficulty remembering
when medication should be taken or what it is prescribed for. It is also useful in situations when
mediation changes have occurred during admission to hospital. This will either be completed by the
pharmacist or the nursing staff. If completed by nursing staff it must be checked by the pharmacist
against the discharge prescription before issued to the patient.
All paperwork associated with the self-medication scheme must be filed in the
patient’s medical notes.
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7.
Audit and review
Multi-disciplinary audits of the implementation and operation of this Policy will be conducted within the
approved wards/departments. The Senior Clinical Pharmacist – Intermediate Care will be responsible
for the audit program and the production of reports and recommendations. These will be presented at
Clinical Audit and other groups as required eg. Nursing Policy Group. Copies of the reports and
recommendations should be provided to the Drug and Therapeutics Committee.
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Self Medication Policy APPENDIX 1
PATIENT CONSENT FOR SELF-MEDICATION
I have read and understood the information leaflet ‘Self-medication’ and had the scheme explained to me by
the nursing staff.
I understand that the medication is for my use only and I am responsible for the key I have been given for the
medication cabinet. I will return this key on my discharge from the ward.
I am aware that a decision may be taken to withdraw me from the scheme if thought necessary by nursing,
medical or pharmacy staff. An explanation for this will be given.
I may withdraw from the scheme at anytime by informing my named nurse.
I have read and understood the above and wish to take part in the self-medication scheme.
Patient
Witness
Name:
Name:
Signature
Signature
Date:
Date:
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Self Meds Policy APPENDIX 2
ALGORITHM FOR THE ASSESSMENT OF
PATIENTS’ ABILITY TO SELF-MEDICATE
INITIAL ASSESSMENT
1. Have you explained the scheme to the patient and supplied the patient information leaflet. Does the
patient wish to participate and if so have they signed the consent form?
●Yes
●No
Level 1
●Yes
Level 1
2. Is the patient confused or unwell?
●No
3. Are there any other patients in the bay likely to cause problems with drug or key custody?
●No
●Yes
Level 1
Refer to Pharmacist then re-assess
COMPLIANCE
4. Was the patient self-administering prior to admission?
●Yes
●No
Level 1
5. Does the patient use a compliance aid (i.e. dosette box, blister pack) to help them with their medication?
●No
●Yes
Level 1
Refer to Pharmacist then re-assess
●No
Level 1 or 2
Continue to question 7 to assess
for level 2
●No
Level 1
Refer to Pharmacist then re-assess
6. Can the patient open the medication locker?
●Yes
7. Can the patient read the medication label?
●Yes
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8. Can the patient open the medication container or blister independently?
●Yes
●No
Level 1
Refer to Pharmacist then re-assess
9. Can the patient dispense and administer the medication independently (i.e. liquids, eye drops, inhalers
etc)?
●Yes
●No
Level 1
Refer to Pharmacist then re-assess
●No
Level 1
Educate then re-assess
10. Does the patient know when to take their medication?
●Yes
11. Does the patient know why they are taking the medication and any of the possible side effects?
●Yes
●No
Level 1
Educate then re-assess
Level 2
12. Has the patient completed an initial period of supervision at level 2 to which the assessing nurse is
satisfied with the patient’s competence?
●Yes
●No
Level 3
Document results of assessments
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Level 2
RESULTS OF NURSING ASSESSMENT OF PATIENTS ABILITY TO SELF-MEDICATE
KEY FOR SELF-MEDICATION
Level 1
Not self-medicating
Level 2
Supervised self-medication
Level 3
Unsupervised self-medication
(Patient must sign consent form)
DATE
ASSESSED
LEV
EL
COMMENTS
Signature
For Pharmacy use only
Results of weekly tablet count for patient on level 3
DATE
COMMENTS/ RESULTS OF TABLET COUNTS
Signature
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APPENDIX 3
PHARMACY
DEPARTMENT
0151 430 1565
SELF
MEDICATION
Patient information
leaflet
Creation Date – July 2007
Review Date October 2013
Produced by Intermediate Care Pharmacist
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WHISTON HOSPITAL
Warrington Road
Prescot L35 5DR
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What is self-medication?
 Self-medication is a scheme which  You will be provided with a medication
chart to help you take the correct dose
will enable you to take your own
of your medicine at the right time of the
medicine whilst in hospital.
day.
 The aim of the scheme is to help you
to gain a greater understanding of Who will supply the medication?
your medicine: If you have brought in your own
- why you are on them,
medicine from home, these will be used
- possible adverse effects from
where suitable.
you medication,
- how and when to take them.
 If you have not brought medicine into
What happens how?
hospital with you, or if new medicine
has been started, these will be provided
 If you are interested in participating in
by the Pharmacy department.
self-medication the Nursing staff or
Pharmacist will explain the scheme in
 The Pharmacy staff will occasionally
more detail.
check the medicine in your locker and
PLEASE NOTE IT IS NOT
re-order supplies.
COMPULSORY TO PARTICIPATE
 The Nursing staff will complete an Where will I keep my medicine?
assessment with you to determine
your ability to self-medicate. This will  Medication will be stored in a locked
cabinet by your bed.
establish any help you may need,
such as large labels or easy to open
 Initially the Nursing staff will help you to
bottles
self-medicate. They will use a master
.
key to open the cabinet at the times
 The Nursing Staff or Pharmacist will
when your medication is due.
explain your medicine to you and
answer any enquiries you may have.

If you are able to self-medicate
without help you will be issued
with your own key to the cabinet.
It will be your responsibility to
keep your medicines in the cabinet
and to keep the key in a safe place.
(Please remember to return your
Key on discharge).
What happens when I am ready to be
discharged from hospital?

The pharmacy staff will use the
medicine in the cabinet to dispense
your discharge prescription.

You will get at least two weeks
supply to take home giving you time
to order a new prescription from
your General Practitioner (GP) and
Pharmacy
REMEMBER THAT MEDICINES
CAN BE DANGEROUS IF NOT
USED PROPERLY
DO NOT EXCEED THE STATED
DOSE
Self Medication Policy Appendix 4
MEDICATION INFORMATION CHART
NAME AND
STRENGTH OF
MEDICINE
WHAT IT’S FOR
HOW MUCH TO TAKE AND WHEN
i.e. how many tablets/sachets/spoonfuls/drops
BREAKFAST LUNCH
EVENING
BEDTIME
MEAL
Nurse Signature:
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POLICY ENDS
SPECIAL INSTRUCTIONS