Various changes have been made to some of our Medicine Codes: 

CODE

SUMMARY OF MAIN AMENDMENTS

Section 08 Ordering Medicines

Stock lists to be reviewed every 6 months. Any extra stock above the agreed top-up levels should be discussed with the Ward Pharmacist or Ward Pharmacy Technician.

Section 10 Transport Receipt of Medicines
  • Medicines Returns Units emptying – information added.
  • Medicines must be removed from any brown paper bags before being placed in the medicine refrigerator.
  • Pharmacy Students on placement – added to transport medicines.
  • Where porters collect and make deliveries to multiple locations each location is in individual sealed or tamper evident container and the packages are transported in a lockable portable trolley – added.
  • The RN/RM/NA responsible for the patient is responsible for ensuring safe transfer of medicines with a patient – added.
  • After ‘top up’ the box of stock medicines received from Pharmacy is retained in secure location, unpacked as soon as possible but no later than midnight the day of receipt.
  • Prior to making any ad hoc orders the stock delivery must be checked.

Section 13a Controlled Drugs General Principles
  • Update in introduction on implementation of eCDR.
  • Update to SOP information in introduction
  • Update on ongoing work to clarify training roles for nurses/nursing associates with CDs with removal of links and previous agreements.
  • Pharmacist can reorder CDs if following clinical screening order needs to be cancelled and re requested
  • Stock reconciliation following recording administration on eCDR
  • Link added DTG97 - Guidance on Administration of Bolus Intravenous Opioids (V1).pdf
  • Importance of counselling patients on the use of oral syringes and the dose of CDs to take
  • Updated links to patient information leaflet
  • Updated links to DTG153 - Naloxone Guidelines (V2).pdf & Use of Midazolam CHFT (V3).pdf
  • Update on management or risks
  • Monitoring requirements updated

Section 13e Controlled Drugs Business Continuity Plan for eCDR
  • Full review.
  • Planned e-learning package for new starters to be available in 2025.
  • If lost supplier support, consider purchasing an alternative electronic solution.
  • Added Nursing Associate (NA) to person who can administer CDS/disposal.

Section 16 Self-Carer-Parent Admin Reuse of POMs
  • In exceptional circumstances, other CDs may be considered for self/carer/parent administration. The RN/RM must discuss with a Pharmacist who will then discuss with the Accountable Officer for Controlled Drugs. If self/carer/parent administration is agreed, an individual process and care plan will be devised between Pharmacy and the Ward and documented.
  • Patients who have a lack of capacity to consent – updated

Section 29 Illicit Drug Substances in the Trust
  • Updated details of Police Liaison Officer
  • Website for reporting concerns - added
  • Refer to eCDR and specific process for illicit substances
  • Pharmacist or Pharmacy Technician involved in process to return to Pharmacy - updated
  • West Yorkshire online system for reporting concerns - added
  • Role of accountable Officer for CDs - updated

Section 35 Monitored Dosage Systems
  • Types of MDS – added.
  • Much of the section about new patients – removed.
  • Much of the section – reworded. Appendix I – removed.
  • Flowchart – amended.

Section 39 Ward Moves Closures Openings
  • Ward medicine keys to be stored in digital lock key safe if ward closes, information about where to obtain each digital lock key code – added.
  • Refer to Ward Opening’ checklist – added.

Section 50 Physician Associate Role & Responsibilities
  • Administration of oxygen/emergency section updated to include information on enrolling on the two-day Advanced Life Support course.
  • Administration of local anaesthetics - Depending on where the PA works, currently this will vary. How to proceed/ discussion/work is planned with the Medical Teams to develop a Standard Procedural Skills Policy for all PAs – added.