Contents
1 Aim
This standard operating procedure (SOP’s) represents the practice for safe completion of ordering, receiving, storing, administration and where necessary disposal of medicines.
2 Scope
The contents of this procedure are applicable to all staff working in non-mental health inpatient wards (Hazel, Hawthorn and Magnolia wards) who are involved in processes of ordering, receiving, transferring, administering or destroying either stock or named patients’ medicines, transcribing and handling FP10’s.
The procedure is made up of a series of at a glance documents covering various areas of managing medicines which are pertinent to the nonmental health inpatient wards. Each document consists of guidance at a trust level outlining the expected standards of practice plus sections to allow an individual service to add clarity or additional guidance specific to that service.
Where a service’s processes cannot conform to the trust level guidance advice must be sought from RDaSH pharmacy services.
3 Link to overarching policy, and or procedure
This SOP is overarched by and to be used in conjunction with the trust’s safe and secure handling of medicines policy.
4 Procedure or implementation
4.1 General
The practical guidance proved by this SOP is contained within a series of at a glance documents which form the attachments to this SOP.
4.1.1 Medicines reconciliation
4.1.2 Medicines transcription
4.1.3 Ordering medicines
4.1.4 Receiving and storing
4.1.5 Medicines administration
4.1.6 Disposal of unwanted medicines
4.1.7 Network unavailable
4.1.8 FP10s and prescription pads, safe use and storage on Magnolia, Hazel and Hawthorn wards
Each document consists of guidance and a sign-off form.
- The guidance section is drawn up into three columns:
- the left-hand column identifies various tasks within the relevant medicine’s management domain.
- the middle column details the minimum expected steps to be taken when carrying out that aspect. It is this column which has been approved through the medicines management and clinical quality and standards committees. This column is not available for teams to amend.
- the right-hand column allows teams to make amendments so that the resultant document is customised to describe the processes in place in their team. Staff identified to be able to carry out particular tasks may be named individually or by role or staff group (for example, qualified nursing staff etc.)
- where a service’s processes cannot conform to the trust level guidance advice must be sought from the RDaSH pharmacy services.
- The sign-off form:
- is for individual staff members to indicate that they have read and understood the document and indicates their intention to comply with the trust and team processes as they apply to managing medicines
- all staff working in the team who handle medicines must sign off against those documents relevant to their role
- This SOP should:
- form part of the new staff member’s induction into the service
- form part of a competency assessment following a medicines error
4.2 Service or team managers
It is the service or team manager’s responsibility to:
- review and ensure that the at a glance documents forming this SOP have been amended as described above to detail the service’s processes around medicines
- ensure all staff members who handle medicines within their service have signed at a glance documents which are relevant to their role
- maintain the SOP to be accurate for the processes in place in the service. Where a process may have changed within the service:
- the existing at a glance document(s) should be archived (with signatures)
- a new at a glance document(s) amended to detail the revised process and circulated to staff for information and signoff
- ensure adequate stocks of order pads, drug cards, stock sheets, and other relevant paperwork are available to support continuous adherence to these SOPs
- processes are in place to ensure secure storage of medicines and appropriate monitoring of that storage (for example, fridge and room temperatures, controlled drugs (CD) registers etc.)
- ensure staff have received and are up-to-date with medicines training as mandated by the trust
- identify where services do not comply with the trust standards and either rectify the process or contact RDaSH pharmacy services for support
4.3 Staff members
It is the responsibility of trust staff to:
- read and sign-off against all at a glance documents, as part of this SOP, which are relevant to their role
- comply with the guidance as detailed within this SOP
- exhibit professional judgement to identify those exceptional instances where a departure from this guidance is required to ensure a patient’s safety. Where such an action has been taken, staff must annotate in the patient record the rationale for the departure and the action taken. It must be reported to the service or team manager
5 Appendices
5.1 Appendix A Medication reconciliation form
5.2 Appendix B Medication transcription checklist
5.3 Appendix C checklist for use of patient own medication
5.4 Appendix D Medication guide
5.4.1 Appendix D1 Medication guide
5.4.2 Appendix D2 Medication guide
5.5 Appendix E Patient information leaflet information for patients for the self administration of medicines
5.5.1 Information for patients for the self administration of medicines
This ward wishes to encourage patients to take charge of their own medicines. However, if you do not wish to be responsible for your medicines at any time, please tell your nurse. This decision will not affect the care given to you in any way.
A nurse will discuss with you whether it is appropriate for you to participate in the scheme.
If you participate you will be given a key to your bedside medicine cabinet, if available, where your medicines will be stored. Your medicines will be labelled with directions. You will be expected to take your medicines at the correct time of day without direct supervision. A nurse will check your prescription to look for any changes in treatment. The nurse will order any new treatment and remove any that has been discontinued.
If you hold the key to your medicine’s cabinet, where available, you must take care to keep it safe to prevent other people from gaining access to your medicines.
Medicines we dispense are supplied with patient information leaflets to help you understand your medicines better, if it will help you understand how to take your medicines you can give your medicines information card that show all your medicines and when to take them.
Occasionally it may be necessary for the nurses to start giving you your medicines again, for example, you may be drowsy after a procedure. The nurse will explain this to you at the time and may remove your key.
Some medicines are considered unsuitable for storage in the bedside locker. This may because the medicines required cool storage, or we may need to make additional records of administration. The nurse will explain this to you.
If suitable we would wish you to use the medicine, you have brought in with you. We will discuss with you whether we think it is safe for you to use them whilst you are in the hospital. On discharge you will be given at least enough medicines to last 14 days and this may include the medicines you brought in with you.
5.6 Appendix F Self-administration of medicines consent form
Document control
- Version: 2.3.
- Unique reference number: 463.
- Approved by: Clinical policies review and approval group.
- Date approved: 7 June 2022.
- Name of originator or author: Pharmacist on behalf of the trust medicines management committee.
- Name of responsible individual: Medicines management committee.
- Date issued: 15 June 2022.
- Review date: May 2024.
- Target audience: All staff.
- Description of change: Minor amendment to phone numbers.
Page last reviewed: December 11, 2024
Next review due: December 11, 2025
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