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Management of medicines on Hazel, Hawthorn and Magnolia wards procedure

1 Aim

This standard operating procedure (SOP) 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 colleagues 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” (AaG) documents covering various areas of managing medicines which are pertinent to the non-mental 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 trust pharmacy services.

This procedure is overarched by and to be used in conjunction with the trusts safe and secure handling of medicines policy.

4 Procedure

4.1 General

The practical guidance approved by this procedure is contained within a series of at a glance documents which form the attachments to this procedure.

4.1.9 Additional documents

Additional documents may be produced as services develop evolve.

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. Colleagues identified to be able to carry out particular tasks may be named individually or by role or colleague group (for example, qualified nursing colleagues).

Where a service’s processes cannot conform to the trust level guidance advice must be sought from the trust pharmacy services.

4.1.9.1 The sign off form

Is for individual colleagues 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 colleagues working in the team who handle medicines must sign off against those documents relevant to their role.

This procedure should:

  • form part of the new colleague’s induction into the service
  • form part of a competency assessment following a medicines error

5 Role and responsibilities

5.1 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 procedure have been amended as described above to detail the service’s processes around medicines
  • ensure all colleagues who handle medicines within their service have signed at a glance documents which are relevant to their role
  • maintain the procedure 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 documents should be archived (with signatures)
    • a new at a glance documents amended to detail the revised process and circulated to colleagues 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 procedures
  • 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)
  • ensure colleagues 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 trust pharmacy services for support

5.2 Colleagues

It is the responsibility of trust colleagues to

  • read and sign-off against all at a glance documents, as part of this procedure, which are relevant to their role
  • comply with the guidance as detailed within this procedure
  • 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, colleagues must annotate in the patient record the rationale for the departure and the action taken and it must be reported to the service or team manager

6 Appendices

6.1 Appendix A medication reconciliation form

Refer to appendix A: medication reconciliation form (staff access only).

6.2 Appendix B medication transcription checklist

Refer to appendix B: medication transcription checklist (staff access only).

6.3 Appendix C checklist for use of patient own medication

Refer to appendix C: checklist for use of patient own medication (staff access only).

6.4 Appendix D medication guide

Refer to appendix D: medication guide (staff access only).

6.5 Appendix E patient information leaflet

6.5.1 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 you 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.

6.6 Appendix F self-administration of medicines consent form

Refer to appendix A: self-administration of medicines consent form (staff access only).

Document control

  • Version: 3.
  • Unique reference number: 463.
  • Approved by: clinical effectiveness meeting.
  • Date approved: 7 June 2022.
  • Name of originator or author: senior pharmacist
  • Name of responsible individual: chief medical officer.
  • Date issued: 30 October 2025.
  • Review date: 31 October 2028.
  • Target audience: all colleagues.

Page last reviewed: October 30, 2025
Next review due: October 30, 2026

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