Kaiyi Manual: Controlled Drugs Management (EN)

Uncontrolled when printed NHS LANARKSHIRE CODE OF PRACTICE FOR MEDICINES GOVERNANCE Section 19 Controlled Drugs (for operating departments please see Section 20) 1. General Information Controlled drugs (CDs) are drugs which are liable to abuse and misuse and are controlled by the Misuse of Drugs Act 1971 and misuse of drugs regulations. Medicines classified as controlled drugs are listed in the current issue of the BNF. Note:

The NHS Lanarkshire Area Drug & Therapeutic Committee, the Acute Clinical Governance & Risk Management Committee or senior nursing and pharmacy managers may recommend that a medicine be treated as a controlled drug even although that drug is not listed as such in the Misuse of Drugs Act 1971. This Section of the Code of Practice outlines the legal requirements for the management of Controlled Drugs. 2. Accountable Officer For Controlled Drugs Each Health Board is required to appoint an Accountable Officer for Controlled Drugs who is accountable for all aspects of the safe and secure management of CDs in his or her organisation.

The NHS Lanarkshire Accountable Officer for Controlled Drugs is Christine Gilmour, Pharmacy & Prescribing, NHS Lanarkshire Headquarters, Kirklands, Fallside Road Bothwell G71 8BB, or contact the NHS Lanarkshire Controlled Drug Governance Team either by email cdgt@lanarkshire.scot.nhs.uk or telephone 01698 858129 3. Responsibilities of the Registered Nurse/Midwife in Charge of the ward or department. The Registered Nurse/Midwife in Charge of the ward, department is responsible for ensuring: - 3.1 The safe custody of the keys of the controlled drug cupboard.

Key-holding may be delegated to other suitably trained, registered healthcare professionals but the legal responsibility remains with the registered nurse or midwife in charge. 3.2 Controlled drug cupboard keys should be kept separate from other keys, and only be given to other approved staff when access to controlled drugs is required. Document Code MedCOP001903 Date Approved 24 Dec 2018 Updated By Director of Pharmacy Review Date 24 Dec 2023 Approved By DOP/Div Nurse Director Supersedes Section 24 Jan 2015 Page 1 of 14

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SECTION 19 – CONTROLLED DRUGS 3.3 Any duplicate key to the controlled drug cupboard must be kept secure at all times and access to this key restricted. Records of access to the duplicate key must be maintained. Pharmacy does not hold duplicate keys. 3.4 The safe custody of the stocks of controlled drugs. Controlled drug cupboards must be kept locked when unattended. 3.5 That all new stock is entered in the ward/department Controlled Drug Record Book immediately on receipt, and that the drugs received match those ordered, and that the total in the record book agrees with the physical stock balance and that this entry is confirmed by the signature of the member of staff making the entry.

3.6 That the regular controlled drug stock check is carried out by staff in the ward or department and that this is recorded. 3.7 Ensuring that procedures laid down for dealing with controlled drugs are complied with. 4 Requisitioning of Controlled Drugs by Wards & Departments 4.1 The registered nurse/midwife in charge of the ward or department is responsible for the requisitioning of CDs for use in that area. Even if the ward or department is managed by someone other than a nurse/midwife, the most senior registered nurse/midwife present is responsible for the CDs.

4.2 The task of requisitioning CDs can be delegated to authorised staff such as a registered nurse/midwife however the legal responsibility for the CDs remains with the registered nurse/midwife in charge. 4.3 All registered nurses/midwives who are authorised to order controlled drugs must supply a specimen of their signature to pharmacy before attempting to order controlled drugs for ward stock. This specimen signature must be authorised by the ward/department/theatre manager. 4.4 Controlled drugs for ward stock must be ordered in a Controlled Drug Order Book (HMSO Code No. 90-500), which are obtained from pharmacy.

4.5 Before an order is written, carbon paper must be correctly inserted between the white top copy and the pink copy, to ensure a carbon copy of the order is obtained. 4.6 All orders must be written in ink or indelible ball point pen. Block capitals must be used when writing an order and the ward/department, drug name, form, strength, ampoule size if more than one available and quantity required must be stated. 4.7 A separate page with carbon copy is used for each preparation ordered. Document Code MedCOP 01903 Date Approved 24 Dec 2018 Page 2 of 14

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SECTION 19 – CONTROLLED DRUGS 4.8 Each order must be signed in full by an authorised nurse/midwife. Initials are not acceptable. 4.9 Any alterations made to an order must be initialled by the registered nurse/midwife signing the order. 4.10 When the order is completed the whole order book should be sent to the Pharmacy Department without removing any pages. 4.11 The Pharmacy department will not make a supply against an incorrectly completed order. 4.12 Any order which is to be cancelled before a supply is made must be crossed with two lines, marked "CANCELLED" and signed and dated by the person cancelling the order. Staff must ensure carbon paper is in place before cancelling the order.

The white copy of a cancelled order must remain in the order book and must not be removed by ward staff. 5 Supply/Delivery of Ward Stocks 5.1 Pharmacy will maintain a set of SOPs for processing requests for controlled drugs. 5.2 Pharmacy will maintain a CD collection log which will provide a full audit trail of all staff involved in the supply and collection of CDs from pharmacy. 5.3 Controlled drugs are delivered to wards and departments in sealed tamper evident security envelopes. 6 Delivery of Ward Stocks 6.1 For delivery of controlled drugs via porter or van driver, the controlled drugs will be sealed in a tamper evident security envelope.

The porter or driver will sign the "accepted for delivery" section, or the CD collection log, before the transit bag is handed over by pharmacy. 6.2 If a member of ward or pharmacy staff delivers the controlled drugs they must sign the "accepted for delivery" section or the CD collection log before leaving pharmacy with the controlled drugs. Document Code MedCOP 01903 Date Approved 24 Dec 2018 Page 3 of 14

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SECTION 19 – CONTROLLED DRUGS 7 Receipt of Ward/Department Stocks 7.1 Each ward/department must have its own Controlled Drug Record Book. These are controlled stationary and are obtained from pharmacy by submitting a written request/indent. 7.2 On Acute Hospital sites pharmacy will undertake to check new Record Books within 72 hours of issue. For off-site locations this will be done within 5 days. 7.3 Controlled drugs delivered to the ward or department must be received by a designated person who must check them against the details in the order book. The registered nurse/midwife receiving the controlled drugs should be a different nurse/midwife from the person who requisitioned them.

7.4 Any discrepancies must be reported to pharmacy immediately. 7.5 If there are no discrepancies, the registered nurse/ midwife must sign the pink copy of the order in the Ward Controlled Drug Order Book. The pink copy remains in the order book. 7.6 The controlled drugs must be stored immediately in the controlled drug cupboard. 7.7 Details of the controlled drugs received must be entered in the Ward/Department Controlled Drug Record Book in red ink or red indelible ball point pen. The right hand column must be completed detailing quantity, form, order number and date. The new balance must agree with the physical stock.

Two registered staff are required for this checking procedure, one of the signatures must be that of the registered nurse/ODP who received the controlled drugs. 8. Storage 8.1 Controlled drugs must be kept in a locked cupboard separate from other drugs. The Head of Pharmacy must approve controlled drug storage areas. The cupboard must not be marked in any way to distinguish it from other cupboards. Colour coding of locks and keys is the preferred method for ease of identification by Ward/department staff if required. 8.2 The key of the controlled drug cupboard must be carried by the registered nurse in charge of the ward and should be kept separate from other ward keys.

8.3 Controlled Drug Record Books and Order Books should be kept in a secure place. 8.4 The controlled drug cupboard must not be used to store any other items, other than strong potassium in those designated critical care areas that are authorised to hold this product. Document Code MedCOP 01903 Date Approved 24 Dec 2018 Page 4 of 14

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