Updated policies including Sepsis Policy and Duty of Candour Policy

Here is a brief description of recent policy changes. Please make yourself aware of the changes, as they may also impact training requirements.

Policies that have been added, updated or renewed within the last 30 days are all stored on the Recent Updates page of the Policies and Documents library. So you can find these documents there or search from the homepage.

Updated:

Sepsis Policy

Reviewed following NatPSA/2025/006/NHSPS Harm from incorrect recording of a penicillin allergy as a penicillamine allergy.
Training and SOPs to support EPR documentation of allergies - added.
Sections reworded to assist understanding
Pharmacist and Pharmacy Technicians can amend the type of reaction as well as prescribers e.g. allergy to ADR.
Cancelled allergies – remove if no allergy e.g. penicillamine allergies removed or where administered and no reaction.

Clarification of when Pharmacy must be involved with medicine storage changes.
Cleaning organised storage - updated.
Review of substances requiring a COSSH entries - updated.
Community process for temperature monitoring - updated.
Removal of packaging to transfer medicines before placing in fridge - updated.
Checklist for medicine carts - updated.
Review of Omnicell Information – future plan to remove and have separate information on intranet.
Addition of date code checking process for community adrenaline.
References to ‘Digi sense’ back up medicines temperature devices removed, and policy updated accordingly.

References to J2O - removed.
The RN must check that that correct formulation is prescribed for the route of administration required and escalate any concerns to the Prescriber and/or Pharmacist if correct formulation not prescribed – added.
Wording under “Check of the patient” heading of section 5 -amended to improve clarity.
Wording under “Omitting medicines in hospital” heading of section 6 amended to improve clarity and old screenshot replaced with updated screenshots.
Exclusion criteria for TNAs updated to include oxygen when a patient is being transferred from the TNA’s Base or Placement Ward/Department.
Acute alcohol withdrawal or acute drug withdrawal treatment changed from Pabrinex to Thiamine.
The barcode should always be scanned unless there is a physical reason why this is not possible, such as a label has been placed over the code. If that is the case, the reason for not scanning the barcode should be clearly documented in the notes.
Students Nurses, Midwives and trainee Nursing Associates can administer eye drops, nasal drops and ear drops.

References to Local Security Management Specialist updated to Healthcare Security Manager.
Change of terminology from Primary to Community Health Care Division.
Fraudulent prescriptions section – added.

Change to location of HRI Emergency Room.
Change to recording of items taken from Emergency Room at CRH site – now using Omnicell cabinet.
Addition to services not provided by Emergency Duty Pharmacist.

Section on the storage, training and administration of Adrenaline Auto-injectors (anaphylaxis) – added.
Registered Nurse and Healthcare Assistant working in Special Schools – section strengthened.
Disposal of medicines and medicines related equipment (including when a child has died) – process updated.
Appendices i, ii, v, vi and viii will move to Systm1 in 2026.