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4. 22nd April 2009 Medicines Management Controlled Drugs e-Learning

5. Aims and Objectives To raise awareness of the legal requirements surrounding controlled drugs (CD’s) To increase confidence when dealing with controlled drugs Highlight changes now we have a NEPFT pharmacy

6. Additional Learning Material  Please use the NEPFT Medicines Procedure tab 10 in addition to these slides  Look on i-Connect/ Policies/ Medicines management/ Policies and procedures/ Tab 10 controlled drugs  Should also be in the hard copy “Medicines Policy Handbook” on each ward/unit  Please print off and put in your Medicines policy handbook if it has not been updated

7. Why Are Some Drugs “Controlled”? Misuse of Drugs Act 1972 and subsequent amendments control and restrict the use of drugs which are abused The purpose of regulation is to ensure ACCOUNTABILITY for the use of certain drugs & to avoid their diversion for improper use The Misuse of Drugs Act divides CDs into 5 schedules according to perceived level of risk. See appendix 1 for list Schedule 1: No medicinal use. Most tightly controlled, require a license from the Home Office to possess Schedule 5: Low strength, less tightly controlled (e.g. Oramorph ordinary strength)

8. Schedule 2: Controlled Drugs  E.g. Methadone, Morphine, methylphenidate  Carry severe risk of addiction  Order using CD order/requisition book  Need to be stored in the CD cupboard  CD register must be completed to account for use

9. Schedule 3: Controlled Drugs  E.g. Temazepam  Ordered through CD order book  Required to be stored in a CD cupboard (except Phenobarbital (Phenobarbitone))  Must be prescribed in full, with quantities in words and figures  NOTE: It is trust policy to treat these as schedule 2 controlled drugs and keep records of their use in most areas (except Phenobarbital), therefore record in CD register

10. Schedule 4: Controlled Drugs  E.g. most benzodiazepines  No legal requirement to store in CD cupboard or to keep records  Pharmacy department monitors use and supply patterns  Accountable officer may designate these as Controlled Drugs if a risk is identified

11. The Need for Increased Governance  Harold Shipman: Acquired large amounts of Diamorphine which he used to kill over 200 patients  New legislation was introduced by the government in response. It is now statutory law. It affects the prescribing, storage and supply of CDs

12. Prescribing Controlled Drugs- Inpatients  All controlled drugs must be prescribed on the PMAC  Unless they are stock, they should also be prescribed on a CD prescription (appendix 10.6) with full details including the home address of the patient, and quantities in words and figures. THIS IS A LEGAL REQUIREMENT  If there is a fully labelled supply on the ward this does not need to be repeated for discharge, as the supply on the ward is the legal property of the patient and can be given to them  You may need to write a CD prescription for short periods of leave as they cannot be secondary dispensed

13. Prescribing Controlled Drugs - Outpatients  Full details must be completed (see BNF page 8)  Remember the FORM and the STRENGTH as well as the dose and other instructions  Total quantity in words and figures. This means number of tablets, patches or ampoules, so you do not have to calculate number of mg  FULL signature and name in block letters, and GMC number  Missing out a detail may result in the patient being sent back by the community pharmacy, and the drugs not supplied

14. Ordering Controlled Drugs from the NEPFT Pharmacy  The CD order book needs to be completed by a registered nurse, countersigned by a ward pharmacist or pharmacy technician and sent to pharmacy  It does NOT have to be countersigned by a Doctor  Dispensing, checking and delivery records are kept by pharmacy  The order book and delivery note needs to be signed when the CDs are received onto the ward  Pharmacy need sample signatures on individual forms  The ward should have sample signatures of ALL register signatories on/in their CD register – updated regularly

15. Receiving Controlled Drugs  Two registered nurses must check that the correct drug, strength and quantity ordered has been supplied  Sign the CD requisition and order book  Enter into the CD register, update balance and physically check the balance is correct. Both then sign the register

16. Storage of Controlled Drugs  CDs must be kept in a locked, designated Controlled Drugs cupboard  Keys must be stored separately from other keys, by the nurse in charge or nominee  Inspected every 3 months by pharmacy  The order books and register must also be kept locked away

17. Checking Controlled Drugs  Ward/unit Manager is responsible for CDs  The stock of the CD being used must be reconciled with the register at the time of administration  Stock should be reconciled with the register when a new supply is received  All CDs must be checked at shift change (appendix 10.5)  All CDs should be checked routinely (weekly)  Pharmacy should check 3-monthly and on request  All discrepancies MUST be reported to your pharmacist or pharmacy on the first working day  The accountable officer (Medical Director) is informed by pharmacy

18. Administration of Controlled Drugs  Must be witnessed by a second registered nurse, from beginning to end of the procedure  If a second nurse is not available, ask a neighbouring ward, or a healthcare asst., doctor or pharmacy staff. Their signature MUST be added to the ward register list  Register entry must include date and time, name of patient, dose given and signatures of BOTH people  Check and record the remaining balance

19. Record Keeping  Each preparation must have separate page  Each patient with a fully labelled supply must have a separate page  Record receiving CDs in red  Record each dose administered  Check new balance and sign (registered nurse and witness)  Any errors should be bracketed and noted as an error with the correct detail stated. Contact pharmacy DO NOT CROSS THROUGH OR OBLITERATE  At the end of the page state the number of the new page, and on the new page state which page it came from unless stock is zero

20. Borrowing Controlled Drugs  In emergency situations, a CD can be borrowed for a specific patient from another clinical area  Patient details must be recorded in the register of the supplying ward  For Methadone, a complete bottle should be transferred if not available from pharmacy in time  Some acute wards keep a stock of Methadone liquid so we have this on site at all times

21. Controlled Drugs at Discharge  Use the fully labelled ward supply or PODs if available  If not the prescriber will need to write a CD prescription (appendix 6) in addition to the 24-hour discharge letter. Contact the ward pharmacy staff to screen the original document and order from pharmacy. Allow enough time  Schedule 2 and 3 CDs MUST NOT be secondary dispensed. It is against the law for nursing staff to supply controlled drugs directly to the patient e.g. from stock CDs on the ward  The CD is the property of the patient once it is dispensed (labelled) specifically for them  The patient or identified representative must sign the prescription upon being given the TTO

22. Patient’s Own Controlled Drugs  Need to be checked and entered into CD register by 2 registered nurses  Should be used on the ward if suitable  If unusable enter in the back of the register. Contact pharmacy staff for destruction. Seek consent if in doubt  Are only to be used for that patient  Remain the property of the patient  Remainder can be given back to patient on discharge

23. Transfer of Controlled Drugs (named patient)  If a patient is transferring from your ward  Check drug and sign out of ward register, stating where they are going to  Contact the receiving ward to ensure they know a CD is coming, or if you can’t send it, to advise them to order it  Ensure the transfer of the drug is secure  Transferring onto your ward  Record details of sending unit/ward  Record full details of drug as if receiving from pharmacy or patient  NOTE Stock CDs can only be transferred between NEPFT wards

24. Liquids  Measure accurately each dose administered  Do not measure the stock balance accurately each time. Enter the calculated balance in the register  Reconcile at the end of each bottle  Small discrepancies must be signed off by two nurses  Larger discrepancies - call a member of pharmacy staff as soon as possible

25. Disposal of Controlled Drugs  Call a Pharmacist/Pharmacy Technician  CDs schedule 2 and 3 must be denatured according to destruction policy. Make sure you have a CD destruction kit on the ward  Amend balance in CD register, check and sign  Destruction of schedule 4 drugs does NOT HAVE to be recorded, but if it may be useful to record it, use the CD register as above

26. Illicit Drugs and Legal Highs  These are not permitted on Trust premises (see Illicit Drugs Policy – Clinical)  They should be confiscated for disposal  Enter in back of CD register and store in CD cupboard  Contact local police drugs officer and pharmacy for destruction ASAP  The CD register and the NEPFT form (appendix 7) MUST be completed when they are destroyed  The form must go to the AD for pharmacy or the Accountable Officer (Medical Director)

27. Summary  There are strict requirements around the supply and use of controlled drugs  These are required by UK law  The NEPFT medicines procedure tab 10 gives detailed instructions on how to manage CDs  If you are unsure please check on i-connect or ask a colleague, especially a colleague from pharmacy.

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