Contents
1 Aim
The aim of this standard operating procedure (SOP) is,
- to improve governance of controlled drugs (CDs) within the organisation
- to provide clarity and consistency for all staff handling CDs
- to define accountability and responsibilities and clarify where responsibility can be delegated
- to ensure practice is in line with the regulatory frameworks
- as a training tool for new and existing staff
2 Scope
The prescribing of controlled drugs within RDaSH aspire drug and alcohol service, Doncaster care group.
3 Link to overarching policy
The overarching policy for this standard operating procedure is the safe and secure handling of medicines manual.
3.1 Standard operating procedure 1, ordering and storage of controlled stationery
Controlled stationery in relation to prescribing includes blank FP10MDA and FP10SS prescriptions, prescription stamps, and prescription order forms.
Ordering of blank prescriptions can only be undertaken by authorised personnel, for example, service manager, Prescription Liaison team, team leader, and non-medical prescribers (NMPs).
Ordering of prescriptions must be done via the correct ordering system. The order form must state the site code for delivery and the receiver’s name, a copy of the email order form is kept at base until the order arrives.
On arrival the invoice is checked off against the product serial numbers, a copy of the invoice is returned to the warehouse and a duplicate copy is kept on file, in a locked cupboard at base.
All boxes of prescriptions incoming to the service or out going to another part of the service must have their serial numbers written up onto a prescription log sheet, as and when used. Hub sites will be responsible for their own records.
All stationery must be stored under lock and key at all times, in a lockable cupboard and key safe and keys or access codes must be kept secure in a key cupboard with designated staff access.
All blank stationery prescriptions deemed as waste must be crossed through as “void” and then shredded before disposal. The serial numbers should be recorded, on the spreadsheet.
Loss or theft of any CD stationery must be reported as soon as possible to the accountable officer, and a record made using the trust IR1 system.
Any patient documentation containing controlled drug prescribing details must be stored securely, in line with the trust’s policies on security of patient records. All hubs to store and log prescriptions as per SOP.
3.2 Standard operating procedure 2, access to prescribing system
The prescribing system is contained on either a static or laptop style computer at treatment base within SystmOne.
Each computer has its own unique login username and password which can be changed completely every 28 days, depending on system.
Each designated member of staff using the system has their own smart card login and password.
Where the computer is static, the password protection (con, alt or del) is used during any times of user absence from the room, and the room is locked using keypad codes.
Where a laptop computer is used, this is removed from the cables and locked away overnight in a secure cupboard.
In line with NHS data security requirements, patient identifiable data should be stored centrally on the trust server. In the event that this is not possible, appropriate encryption software must be used. If staff are working from home the laptop must be kept safe and secure with use of passwords and kept in a secure environment.
Staff members with prescription writing permissions can set up prescribing templates, amend and print prescriptions they must have received training on how to use the SystmOne prescribing function accurately.
3.3 Standard operating procedure 3, pharmacy requests via pharm outcomes or telephone
In order to protect patient confidentiality, staff members telephoning a pharmacy or other agency for client information can exercise good practice by using a password system to verify their identity; the agency can follow this up with a phone call back to the treatment service if they are still unsure.
Any requests are dealt with by the pharmacist or manager in the first instance and a designated member of staff in the second instance.
All telephone requests to action a change on a prescription must be followed up by written confirmation sent via pharm outcomes to the pharmacy. This must be done by completing the necessary template on pharm outcomes.
Examples of use for this template could include stopping a prescription for clinical reasons, change in dose resulting in a replacement prescription, or information to be passed onto the client regarding appointments, and so on.
The pharmacies and aspire have an unofficial agreement that the pharmacy will store this information and pass it onto other staff at the beginning and end of each shift.
Any messages from the Pharmacy to the treatment service are entered onto SystmOne by the prescription co-ordinators. The key worker will be tasked if the prescription has been discontinued or there has been an adverse event at the pharmacy.
3.4 Standard operating procedure 4, changes to prescriptions or new prescriptions
All prescriptions or repeat templates will be generated by the prescriber or pharmacy liaison officer, following instruction from a prescriber, on to SystmOne.
Changes to prescriptions can be made by the prescription co-ordinator when tasked by the prescriber.
All medical plans will be documented by the prescriber within the client’s record; any changes to dose or pickups requests from the key worker must go direct to a prescriber for authorisation.
Any routine changes such as change of dose or pickups requests should usually be done when the next batch print is run, which is generally every 2 weeks. However, if a prescriber feels this should be sooner, they should task the prescription coordinator with a specific date they want to change to be effective from. If a prescription is to be interrupted a message via pharm outcomes preceded by a telephone call to the pharmacy should be made. The telephone call can be made by prescriber or key worker who will then task prescription liaison officers with the information.
When a prescription has been cancelled via pharm outcomes the pharmacy are advised to action this as completed on their local prescription management system.
3.5 Standard operating procedure 5, prescription reprints
Reprints of prescriptions can occur for a variety of reasons from the pharmacy accidentally destroying it, too it getting crumpled up during being printed or printer error.
If a prescription does require a duplicate print, where possible the original prescription (regardless of the state it is in) should be supplied for the signing doctor or clinical specialist to see, prior to any re-prints being run off or issued. Where the original script is not available, reprints must be recorded on the prescribing system.
Any destroyed prescriptions must be crossed through as “VOID”, and then shredded into confidential waste bins. The serial numbers should be recorded and witnessed and signed by two members of staff.
Any further information is written into the client’s electronic patient record system(SystmOne).
3.6 Standard operating procedure 6, prescriptions in hub sites
Clinical specialist in the hub to ensure that a new box of prescriptions is signed into the prescription logbook or electronic spreadsheet and note made of serial numbers.
Clinical specialist to turn prescriptions face down when box opened. Make note of first prescription number, sign and date at beginning and end of each shift into logbook or electronic spreadsheet. Note that the first prescription number should match the last number recorded at the end of the previous day.
Any discrepancies to be investigated immediately. Clinical specialist to advise prescription liaison officer and complete IR1 if needed.
All blank prescriptions should be locked in safe or lockable cupboard when not in use. No prescriptions should be left in printer when not in use. Access code held by all clinical specialists. This code can be given to band 6 member of staff in emergency situations and with agreement from a clinical specialist or doctor.
Clinical specialist will identify when stock is low. Either clinical specialist or nominated staff member will collect a new box of prescriptions from the prescription liaison officer and sign for it.
New box needs to be signed in at the hub and kept in the safe. Any prescriptions held back for collection by patient must be logged and kept in designated file. File must be stored safely during open hours and collected prescriptions to be logged onto patient records. Hold back file to be kept under lock and key when hub is closed.
A key safe will be held at all hubs containing the safe key, this will be the same code as the safe. This will be used if there is a problem opening the safe with the code. Any prescriptions destroyed need to be logged and signed for by prescriber and one other. Reason for destruction (patient not collected, printer error, damaged and so on.) to be noted. Prescription must be crossed as void and shredded or put into confidential waste.
3.6.1 Auditing
The audit should be carried out every 6 months by band 6 member of staff or above.
The audit will include:
- checking the required safes are in operation
- checking that all recording has taken place
- blue and green prescription numbers are recorded at beginning and end of each clinic and no discrepancies in serial numbers. (Numbers on prescription log tally)
- destroyed blank prescriptions are being recorded by prescriber and one other staff member
- all printed prescriptions not collected are destroyed and recorded. Signed by two members of staff
3.7 Standard operating procedure 7, audit of batch and repeat prescriptions
Every week or fortnight the batch of ongoing repeat prescriptions is printed off using the prescribing batch print function and prescription search function. The batch is printed directly to the printer located in the prescription liaison office. The only people able to print these batches are the prescription liaison officers and allocated trained others if prescription liaison officers are both absent.
The batch of prescriptions is signed by a designated prescriber.
In order to audit the production of prescriptions, each month a minimum of 5 random prescriptions are pulled from the batch and double checked against computer medication record, and client file information.
The most appropriate person to carry out the audit is the doctor or clinical specialist signing the batch; however, any senior member of staff is appropriate providing they are different to the person who has printed the script. Both the printer and auditors’ names should be stated on the audit form.
A record of the prescriptions audited is kept in a file and archived every three years. In some services this can be stored electronically (via scanning) on the L Drive. If the auditor did find a discrepancy in the prescriptions, an internal investigation by the team leader would be the first route of enquiry.
The batch prescriptions are kept in the prescription liaison officers office. No batches are carried out or kept at hubs.
3.8 Standard operating procedure 8, Prescriptions covering bank holiday periods
Treatment services are closed during periods of public bank holidays. Although most pharmacies close, a very small number may open on a duty rota basis, although not necessarily in a way that easily facilitates substitute prescription dispensing or supervision (for example, restricted hours).
The fact that the duty pharmacy may not be geographically suitable for the majority of clients, particularly if public transport is unavailable, has meant that it is not feasible to provide a normal dispensing service.
This means that clients will normally pick up on the day proceeding a bank holiday and will be given enough medication to last until the pharmacy re-opens after the bank holiday, when pickups will resume as normal.
In the event that bank holidays occur adjacent to weekends, the risks associated with dispensing a larger than normal amount of medication should be considered, particularly for those patients who collect daily, but whose local pharmacy does not open on a Saturday.
In certain circumstances (for example, where Christmas Day or Boxing Day fall on a Thursday or Friday), consideration should be given to temporarily re-locating clients, identified by either key worker or pharmacist as presenting high risks to a pharmacy where Saturday collection is available.
It is the key worker’s responsibility to inform clients about any changes to their pickup days, this is usually done via written letter, verbally, and via notices displayed on service premises.
Every effort to maintain safety of large volumes of medication is taken into consideration, clients can be dispensed in daily dose bottles following a prescription amendment and are advised on means of suitable storage of medication.
Pharmacy contractors will receive the batch prior to the bank holiday. The bank holiday batch will be collected as normal on a Friday. If the bank holiday falls on a Friday, the batch will be collected on the Thursday prior. Pharmacists will also be asked to check any prescriptions as soon as they are received to allow opportunity for amendment or reissue if incorrect.
3.9 Standard operating procedure 9, distribution of prescriptions
The mechanism for distribution of prescriptions can fall into four categories.
- Collection by pharmacy representatives, direct from the drug team identification is sought and a sheet is signed off relating to the pickup
- Direct delivery to the pharmacy by pharmacy liaison officers or aspire staff, A sign off sheet is written up and kept at base relating to the delivery
- Collection by client from base, Identification of client is determined by checking name address and DOB. A sign off sheet in the client’s file is also completed. This will include the serial number of the prescription, the drug prescribed and dates on the prescription. The date signed into the file and out will also be recorded. In exceptional circumstances a third party may be needed to collect a prescription for a patient. Request to be send by key worker to doctor or clinical specialist who will advise the prescription liaison officer. The patient will need to identify the third party who will need to provide identification on collection of the prescription. The pharmacy is to be advised of the identification of the third party. Any third-party collections are to be used for the minimum amount of time possible. The following policies should be taken into consideration:
- Mental Capacity Act
- privacy, dignity and respect
- safeguarding
- fraud
- infection control
- risk management
It should be noted that once issued, the client is responsible for safe custody of the prescription until handed to the pharmacist. Prescriptions lost or damaged by the client will not be replaced.
- Postal delivery to pharmacy via Royal Mail, This should only be used when other methods are not feasible, and only where patient stability is such that this is clinically appropriate. The envelope is securely sealed, and the package is weighed and stamped or franked accordingly. The package is taken to the mail sorting office to avoid delays with post boxes. Recorded or special delivery must be used.
3.10 Standard operating procedure 10, record of prescriptions printed or delivered
Every week the batch of on-going repeat prescriptions is printed off using the prescribing reports on SystmOne.
A copy of the report is saved electronically within the L drive.
A copy of reports are put in the relevant pharmacy envelopes to be checked on receipt. This enables any discrepancies to be dealt with immediately.
A log is kept of all prescriptions delivered to the pharmacies, collected by pharmacy delivery drivers, posted out to the pharmacies, or given direct to clients.
This log acts as a point of reference if any prescriptions go missing or are lost. The logs are kept for up to one month or until the dates on the prescription have passed and it is no longer current.
The first and last serial numbers of prescriptions in the batch should be recorded each time the batch is printed.
The first and last serial numbers of prescriptions printed should be recorded daily in a hard back book or electronically. The first number of the next prescription in the box should also be recorded and this should be checked as correct the following day prior to placing in the printer.
This record should be kept in all the sites where clinics are carried out and prescriptions are printed.
4 Appendices
Appendix A Aspire batch audit
Document control
- Version: 5.
- Unique reference number: 137.
- Date approved: 05 November 2021.
- Approved by: Clinical policy review and approval group.
- Name of originator or author: Clinical nurse specialist.
- Name of responsible individual: Medicine management committee.
- Date issued: 17 November 2021.
- Review date: November 2024.
- Target audience: Aspire drug and alcohol service (community staff involved in all aspects of delivering controlled drug prescribing).
Page last reviewed: April 23, 2024
Next review due: April 23, 2025