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Standards for ordering and receiving of medication

Contents

  1. Aim
  2. Link to overarching manual
  3. Responsibilities, accountabilities and duties
  4. Ward or clinic stock
  5. Receipt of medication
  6. Named patient medication
  7. Controlled drugs
  8. Transferring medication between wards
  9. Out of hours

1 Aim

The aim of this document is to set down the standards for ordering and receiving medication.

2 Link to overarching manual

This document links to the overarching Safe and secure handling of medicines manual and the inpatient standard operating procedures (staff access only) (opens in new window).

3 Responsibilities, accountabilities and duties

Are in line with the overarching policy, unless otherwise stated within this policy. Medications may be ordered by:

  • authorised pharmacy staff
  • nursing staff
  • ward based technicians
  • clinic managers
  • prescribers

4 Ward or clinic stock

  • All wards have a list of stock medicines agreed between the ward, pharmacy, and the supplying pharmacy.
  • Community clinics stock list will be determined by the clinic manager dependent on the patient cohort.
  • Frequency of review should be informed by any changes in patient grouping or practice. This should be done as a minimum annually.
  • Pharmacy or ward technician staff are responsible for a weekly top-up of stock medicines to agreed levels there should be a minimum of 10 days medication available.
  • Ward nursing staff may have to order some medications if usage has changed between technician top-ups.
  • Ordering must be done on the non-stock pad (form WZT696).
  • There must be only a single order book in use at any one time.
  • Orders must:
    • have ward or clinic name and date and contact phone number
    • have full drug name, strength, and quantity details
    • be signed by an authorised member for staff
  • Orders are to be signed scanned and emailed to the supplying pharmacy and the original copy must be sent using a secure pouch or medicines box.
  • Delivery of stock orders is between Monday to Friday for those orders placed by 1pm the previous day.
  • Urgent stock items within hours:
    • Check other onsite units and arrange transfer (see below)
  • If unsuccessful use to take out (TTO) ordering specifically for patient (see below). All stock items will be delivered in either a sealed box or satchel. There should be a tamper evident closure.

5 Receipt of medication

  • All stock orders will arrive with a delivery note.
  • The stock should be checked off against the delivery note by an authorised member of staff.
  • Where stock is known to be missing by the supplying pharmacy there will be an ‘owing slip’. Staff should attach the owing slip to the delivery note for later reconciliation.
  • Any owing, missing or inappropriate stock should be brought to the attention of the team manager or senior clinical staff on shift to identify relevant actions.
  • Missing or inappropriate stock must be brought to the attention of the supplying pharmacy for rectification.
  • Stock should be stored in the appropriate locked drug cupboard ensuring all stock is rotated so that stock with the shortest expiry date is available for first use.
  • The relevant stock medicines reconciliation forms should be updated to reflect new stock levels.

6 Named patient medication

  • ‘Patient specific medicines’ refers to instances where a medication will be dispensed and labelled specifically for a particular patient. Examples of these are:
    • medication for patients going on leave
    • TTO
    • urgently required medicines or those where the delay in receiving “stock delivery” would lead to a gap or undue delay in medication which would be detrimental to patient care
    • community clinics, in agreement with the chief pharmacist the clinics may use TTO pads or appropriate FP10’s
  • The default process for generating prescriptions for patient specific medicines for inpatients is to generate them using SystmOne TTO functionality:
    • these should be printed and then signed by the prescriber
  • In exceptional circumstances and for community clinics, for example, when the electronic record is unavailable and delay in ordering would lead to an unnecessary delay in getting the medications (for example, delayed start to antibiotics or discharge) manual TTO pads (form WZT697) are able to be used. It should be documented for community patients what medication is being supplied by the trust and which by the patients GP:
    • there must be only a single manual TTO pad in use at any one time
    • manual ordering of patient specific medications must be done on the trust TTO pad by an authorised member of staff and contain the following information:
      • patient identifier (name, DOB (date of birth) and address, NHS number)
      • drug strength, dose form, dosage details and quantity (maximum of 28 days as appropriate clinically or for the level of patient risk)
      • rationale for quantity should be part of the discharge care plan
      • the prescriber’s name
    • patient specific requests must be signed and dated by an authorised prescriber following printing
    • the signed copy of all manually written TTO’s must be scanned and entered into the relevant clinical record and a note made in the record of the need to manually prescribe
  • FP10’s, they should routinely be electronically generated and sent to the Pharmacy using electronic prescription service (EPS) functionality of SystmOne, where not possible then they may be written by hand or computer generated. Where handwritten then a corresponding entry must be made in the clinical record.
  • For the initial ordering of an unlicensed medicines (products that do not have a product licence in the UK, this is not when medicines are being used outside their licensed indications), RDaSH pharmacy must be informed before ordering.

Completed forms are to be signed, scanned, and emailed to the local pharmacy provider; the original must be sent using a secured pouch or drug box.

  • Copies of the order (either computer generated TTO copy or yellow carbon copy if manually generated) must be placed in the pharmacy folder for checking upon delivery.
  • Clozapine ordering:
    • all clozapine ordering is done as named patient orders.
    • existing clozapine patients will come onto the ward with their supply and Lloyds Pharmacy will continue to supply against the original prescription unless there is a dose change, or the original prescription expires.
    • the ward will need to let their Lloyds Pharmacy supplier know when the patient has been admitted and discharged.
    • new clozapine patients or prescriptions are done on the TTO form with the prescription length being determined by dose titration or stability of monitoring.
    • if a patient arrives out of area on a different brand of clozapine, for example, Clozaril then the clozapine clinic must be informed to allow transfer to the agreed brand. The patient’s existing stock can be used until then as long as it is deemed to have been stored properly, is correctly labelled, and they still have a valid blood test
  • NOMAD or other monitored dosage systems required for TTO, this must be clearly indicated on the TTO and arranged well in advance of discharge:
    • where a new NOMAD is considered clinically appropriate, prior to discharge an identified pharmacy must be contacted to ensure continuity of supply. They will need to be contacted for agreement to this plan
    • where deemed appropriate patients can be referred to the discharge medicines service to facilitate a check and review in the community

6.1 Receipt of named patient medication

  • Patient specific medicines will be delivered in a clear plastic bag, in either a sealed box or satchel. There should be a tamper evident closure.
  • The patient specific medicines should be checked off against the delivery note by an authorised member of staff.
  • Patient specific medicines should be stored in the appropriate locked drug cupboard awaiting check by qualified staff.
  • The relevant reconciliation forms should be updated to reflect new stock levels.
  • Authorised qualified staff should check:
    • all dispensed medicines are accurate against the prescription chart
    • the quantities are appropriate for delivery of original dispensed packs only
    • patient information leaflets are available
  • Any patient named controlled drugs (CDs) must:
    • be entered into the back of the CD register by a qualified member of staff and a witness, use a separate page for each patient and drug
    • stored in the CD cupboard

7 Controlled drugs

  • Staff should refer to the trust’s full inpatient standard operating procedure (SOP) for controlled drugs (CD) (staff access only) (opens in new window).
  • All CDs are to be ordered in one of two ways depending on if they are stock or named patient. There is a trust wide list agreed with Lloyds of CDs which can be ordered as stock. All other CD’s need to be ordered as named patient. A list of these stock CDs may be found on the wards, and pharmacy can be contacted if needed.
  • Stock, to be ordered on a ward CD order book (WOP100). This requires:
    • full drug name, strength, and quantity details. Quantity must be in words and figures for stock use
    • signature and date, entered by a doctor
  • Completed requisition book must be sent in the box to the ward’s wholesaling Lloyds Pharmacy
  • TTO or leave medication or urgent, to be ordered as per patient specific medicines. Details as per patient specific medicines above plus:
    • quantity in words and figures
    • signature and date, entered by a prescriber
  • Methadone for opioid dependence is not ordered as part of a TTO. Patient should be referred to the appropriate substance misuse service before being discharged
    • completed TTO forms must be sent in the box to the ward’s local Lloyds Pharmacy

7.1 Receipt of controlled drugs

  • All stock CD items will be delivered in either a sealed box or satchel. There should be a tamper evident closure. This will be separate to other stock.
  • Stock will need to be checked against the CD requisition book and the delivery note.
  • The delivery note must be signed and given to the driver as proof of delivery for the pharmacy.
  • Stock should be stored in the CD cupboard ensuring all stock is rotated so that stock with the shortest expiry date is available for first use.
  • The CD register should be completed by a qualified member of staff and a witness, ensuring the total balance is correct.
  • Any discrepancies should be reported to the clinic or ward manager and the trust CD accountable officer (via the pharmacy department).

8 Transferring medication between wards

  • All transfer of medicines onto the ward and out of the ward must be recorded along with the name of staff involved and the receiving ward in the transfer book on both the source and receiving the ward.
  • In exceptional circumstances stock may be transferred between wards and community teams in the following circumstances:
    • out of hours or urgently required items
    • transferring specific medication, for example, clozapine, named patient medication following the transfer of a patient
  • There must be only a single transfer book in use at any one time
  • The Transfer of Medicines book (DP3628) must be completed on all occasions and must contain:
    • a record of medicines transferred onto the ward AND medicines transferred off the ward
    • the names of both wards involved
    • the date, drug details and quantity
    • a signature from a qualified nurse
  • CDs must not be transferred. Wards should individually dose from another ward while awaiting stock to arrive.

9 Out of hours

  • Stock items are available Monday to Friday, refer to contact sheet for relevant hours and cut off times.
  • Outside of normal hours staff should consider:
    • local RDaSH wards for non-CD stock transfer first, then refer to contact sheet for relevant local pharmacy supplier hours and order via TTO paperwork and processes. No delivery service is available, so request will need to be collected
    • urgent requests up to 11pm can be handled by the local pharmacy provider, see ward based SOP’s for specific location details
    • urgent requests after 11pm will be handled through Lloyd’s wholesaler (AAH), see contact sheet for details, this attracts a £300 callout fee

Document control

  • Version: 2.
  • Unique reference number: 552.
  • Approved by: Clinical policy review and approval group.
  • Date approved: 7 March 2023.
  • Name of originator or author: Medicines management committee.
  • Name of responsible individual: Executive medical director.
  • Date issued: 26 March 2023.
  • Review date: 31 March 2026.
  • Target audience: Trust wide.
  • Description of change: 3 year review.

Page last reviewed: October 29, 2024
Next review due: October 29, 2025

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