v.1.0 Date: December 2015 Cathy Riley - Director of Pharmacy Policy and Procedures Committee Policy and Procedures Committee

Transcription

1 Clinical Preparation and administration of Controlled Drugs against a prescription SOP Document Control Summary Status: Replacement Controlled Drug Policy Version: Author/Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures v.1.0 Date: December 2015 Cathy Riley - Director of Pharmacy Policy and Procedures Committee Policy and Procedures Committee Date: Date: Medicines Optimisation Strategy : Making the most of medicines February 2016 December 2018 Controlled Drugs Medicines Code 18/02/ /02/2016 Contents 1. Introduction Purpose Scope Procedure Process For Monitoring Compliance And Effectiveness References... 5

2 Change Control Amendment History Version Dates Amendments v.01 December 15 SOP Page 2 of 5

3 1. Introduction SOP applies to all clinical areas of South Staffordshire & Shropshire Healthcare Foundation Trust, except prisons and community substance misuse teams which have individual SOPs developed. 2. Purpose To ensure the accurate prescription validation and preparation of the dose of controlled drug prior to administration of the CD and the subsequent entry into the CD register. 3. Scope This SOP covers: Validation of the prescription Preparation of the dose against the prescription Entry into the CD register of doses administered/supplied 4. Procedure Validation of the prescription It must not be assumed that the person prescribing the CD is authorised to do so. Care must be taken by staff to ensure as far as reasonably possible that the prescription is valid. NB FY1 doctors are not able to prescribe Schedule 2 or 3 CDs for leave, discharge or for out-patients. If in doubt of the validity of the signature, steps must be taken in order to verify their authority to prescribe. Preparation and administration of the dose against the prescription The procedure for administration of a CD is the same as for other Medicines as laid down in the Trust s Medicines Code. In addition: The person administering must be aware of the following characteristics of the medicine and formulation: usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose and common side effects. When a dose increase is prescribed, the calculated dose should be checked to ensure that it is safe for the patient, not normally more than 50% higher than the previous dose.(see section (2) Any dose that appears to be unusual should be confirmed with the prescriber. Page 3 of 5

4 The administration of any controlled drug requires double checking by another authorised employee (ideally and usually a registered nurse Where two authorised employees are involved in the administration of CDs, one of them must be a designated practitioner (registered nurse). Both should be present during the whole of the administration procedure. They should both witness: o The preparation of the CDs to be administered. o The CD being administered to the patient. o The wastage/destruction of any surplus drug (e.g. part of an ampoule infusion not required). A record should be made in the ward or department CD Record Book when a schedule 2 CD (or Buprenorphine used for substance misuse/subutex) is removed from the CD cupboard. Both staff must have seen a valid prescription for the CD Liquid CDs can often be marginally out due to small but repeated errors in the measuring process, causing problems on reconciliation. This can be reduced by using the smallest measuring device possible e.g. oral syringes for lower doses. Staff administering CDs must be competent to recognise and treat any patient deterioration and/or any known adverse effect that required immediate life support intervention, such as anaphylaxis, cardiovascular collapse, and respiratory depression. Substance misuse patients may need close supervision of their doses to ensure that they have actually taken the medication. Staff should be aware of those that need extra scrutiny and the consequences of incomplete administration Entry into the CD register of doses administered/supplied Details of the administration for Schedule 2 CDs and Buprenorphine used for substance misuse/subutex must be recorded in the ward CD Record Book, together with a full signature of both the witness and the person who administered the drug. The Record Book must be completed immediately following the administration of the CD. Any dose of a Schedule 2 Controlled Drug or Buprenorphine used for substance misuse (Subutex) that is prepared but not administered, including partly used syringes used in syringe driver pumps shall be destroyed on the ward or department. It shall be destroyed in the presence of the witness and a record made in the CD Register, to that effect stating the amount administered and the amount wasted, which includes the signatures of the 2 practitioners involved in the destruction. It should be rendered irretrievable by emptying into a sharps bin. The emptied vial or ampoule should then also be placed in the sharps bin. Page 4 of 5

5 When the bin is sent for destruction it should be labelled contains mixed pharmaceutical waste and sharps for incineration 5. Process for Monitoring Compliance and Effectiveness Audits relating to different aspects of the CD SOPs will be carried out at regular intervals as part of the ward CD audit and annual medicines management audit. 6. References Page 5 of 5