CONTROLLED DRUGS ACCOUNTABLE OFFICER ANNUAL REPORT

Transcription

1 CONTROLLED DRUGS ACCOUNTABLE OFFICER ANNUAL REPORT Prepared by Anna Zamczyk GPhC July 2016

2 Introduction Healthcare organisations have a responsibility to manage their controlled drugs responsibly and in accordance with the law. In the East of England Ambulance Service (EEAST) had two Controlled Drug Accountable Officers (CDAO): Rob Ashford, Locality Director for Essex, followed by Sandy Brown, Director of Nursing and Clinical Quality. The Care Quality Commission (CQC) was informed on the occasion of each change and details added to the National Database. The day to day management of Controlled Drug (CD) affairs has been devolved to Anna Zamczyk, Pharmacist and Head of Medicine Management (HMM), who collates information gathered through the Trust incident reporting system (Datix) and other sources, generates reports and oversees safe management of CDs on Trust premises. The Medicines Management Group (MMG) chaired by the Consultant Paramedic, determines policy and procedure in relation to CD management and ensures action is taken in relation to incidents and that learning from incidents is embedded through the Trust. EEAST submits a quarterly CDAO report to the 4 regional Local Intelligence Networks (LINs) where information is shared. During the Trust reported 161 CD incidents. Action Highlights Minimise loss and breakages of CDs - clinicians stopped carry CDs and CDs pouches on their belt and in a pocket since October Withdrawal of Co-Codamol 30/500 tablets from the Trust and replaced them with Paracetamol 500mg caplets and Ibuprofen 200mg tablets in December All CDs Incident from previously quarter sent directly to SLMs for awareness and lessons learn since January Medicines Management Proforma developed (with all required meds management actions) completed by DLO for each station within their group, approved by SLM, on a quarterly basis since December 2015 New CSOP05 - Disposal of Out Of Date Drugs and Denaturing of Controlled Drugs was implemented across the Trust in March 2016 On site visits by HMM and Quality Development Team (QDT) to provide assurance that current systems are safe, follow up with estates for medical gas storage. Review and carry on spot checks local teams to feedback any issues with the process. CD management improvement of the structure in some areas (example separate out of date and in date CD drug storage). Morphine checks straighten process morphine checks both on individuals and stations. Audit on February data Trust wide and follow up all gaps. Non-Clinical staff was trained on every station to take function Trust Approved Witness of Controlled Drugs Destruction. Continue station spot checks, if process is in place. Page 1 of 4

3 Work on AuditR Medicines Management Audits - Medicines Management Online Application for Audit Entry. Trial of the AuditR system with Medicines Management audits in Beds & Herts and HART is planned since June 2016 The Medicines Management Storage and Supply Chain Project Options Paper was produced by the Project Team and will be presented to Executive Leadership Board (ELB) in June CDs serious incident (SI) There were two CDs serious incident (SI) investigations undertaken during : 1. On 20 April ampoules of Diazemuls 10mg/2ml were reported to be missing from James Paget Hospital A&E drugs cupboard used by ambulance personnel. Over a period of 18 to 24 months, a large quantity of tablet-based medication was lost from one ambulance station within a Waveney locality of the East of England Ambulance Service NHS Trust (EEAST) region. This loss of Co-Codamol tablets was initially noticed in small numbers, gradually increasing to several hundred tablets in the four-month period of January to April During April 2015 a significant loss of Paramedic-only administration drugs was identified. This loss of Diazemuls was isolated to a specific drugs cupboard located within one hospital setting, and later in the same month a loss of Diazepam was noted from an EEAST vehicle drugs bag. These losses resulted in a Datix (incident report) being submitted and an investigation being launched by local Managers. Suspicions had been raised that these losses involved one member of EEAST staff, although there was no confirmed evidence that this member of staff was involved. Following the Police search, the member of staff was found in an unconscious state in a hotel room, with Trust issued medications and drug paraphernalia at his side. The patient was treated by ambulance crews and taken to hospital, where he remained for an overnight stay and was discharged home the following afternoon. He remains suspended from work and is receiving support and counselling from various agencies and societies. The investigation has identified the following lessons from this incident: Pre-employment checks on a Direct Entry applicant did reveal previous allegations and investigations of drug mis-use during his employment in another NHS Ambulance Trust; however whilst we believe this information was passed to this Trust in good faith, it was in contradiction to Employment Law, and should not have been revealed. Despite this revelation, he was still employed by this Ambulance Trust from 2004 onwards. The ability of drugs to be removed from an ambulance response/drugs bag and retained by a person with ease, with no record of these drugs being taken. The alpha-numeric code for access to a secure drugs cupboard was written on the door, enabling anyone to gain access. An alarm system installed at the drugs cupboard to sound an audible warning when the doors remain open is not loud enough and is easily silenced. Keys for controlled drug lockers are being left in the doors, even though the locker is empty Page 2 of 4

4 2. Morphine stolen from member of staff s personal car. On 19 December 2015 at 18:45 a Paramedic working for the East of England Ambulance Service NHS Trust finished their shift for the day. At approximately 19:00 the Paramedic arrived at their home address and locked their personal car with NHS property, including Controlled Drugs (CD s), inside the boot which included ten Morphine Sulphate 10mg/1ml ampoules and one Oramorph 10mg/5ml bottle. The following day on 20 December 2015, as the Paramedic was leaving for their shift, the Paramedic found the rear driver s side car door ajar. Upon inspection it became apparent that the CD s, other Trust property and various personal items belonging to the Paramedic were missing and believed stolen. The Paramedic informed the Police and reported the incident to their line manager when they arrived for their duty shift later that day. The investigation has found that the Paramedic could not lock their controlled drugs away at the ambulance station as although a morphine safe was issued to the Paramedic, there was no key issued to lock the safe with; therefore it could not be used. The investigation has also found that there were other available safes with keys that could, and should, have been issued, in line with the Trust s Medicines Management Policy. The Crime Scene Investigation team investigated the scene of the incident and concluded that the contents of the car had been stolen. The Police have since closed this investigation due to a lack of material evidence. The investigation has identified the following lessons from this incident: Insufficient training for Paramedics and DLO s in the safe storage of CD s Insufficient contingency planning for shortages in safe storage Failure to appropriately follow established policies, in this case safe storage, can lead to the loss of Trust equipment and supplies. Failure to establish and make use of effective lines of communication between operational staff and managers can result in important administrative tasks going unfulfilled. Failure to appropriately prioritise non-operational tasks can lead to significant breaches in Trust policy. All CD s should be appropriately stored and the intentions of The Medicines Management Policy should be adhered to at all times. If keys to designated safe storage facilities are lost they must be replaced as a matter of urgency. Page 3 of 4

5 Number of incidents There were a total of 161 reportable controlled drugs incidents by Datix system, however during one report often e.g. few ampoules of CD were broken or few tablets of Co-Codamol were missing. The below tables show the exact number of CD tablets and ampoules involved in incidents during Morphine 10 mg injection Oramorph 10 mg/5 ml Diazemuls injection 10 mg/2ml Diazepam rectal 5 mg/2.5ml Diazepam rectal 10 mg/2.5ml Diazepam 5mg tablets Co-Codamol 30/500 tablets Red Book CD Register Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Break Loss Excess 1 2 Accounting (resolved) Security Issues Problem with CD restock Individuals of Concern 2 Total

6 Breakdown by Region No. of Incidents % Total Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Waveney Norfolk Suffolk Cambridgeshire Bedfordshire Hertfordshire Essex HART Great Notley HART Melbourne The 564 individual drugs incidents can be classed as: 459 classed as a loss from which 365 items relate to of Co-Codamol tablets lost during Q1,Q2,Q3 wherefore this drug was withdraw from the Trust in Q4 57 classed as breakages 3 classed as excess (confirmed by a witness) 2 classed as an individuals of concerns 36 classed as an accounting errors that have been fully resolved 7 classed as security problems Loss of Morphine cabinet key leave open cupboard with CDs Lack of supervision over the supply of CDs 0 classed as problem with CD re-stock In comparison in year we have had 19 incidents relating to re-stock problems. To improve the management of medicines with the Trust, the medicnes management team will increase in next financial year to 3 people team. Benchmarking with other Ambulance Trusts in the UK has shown, that EEAST in reported higher levels of incidents related to the loss of morphine and diazemuls ampoules.

7 CDAO on behalf of the Trust Sandy Brown Director of Nursing and Clinical Quality July 2016.