Contents
1 Aim
This standard operating procedure (SOP) covers the destruction of RDaSH requisitioned:
- stock controlled drugs (CDs) including unlabelled and patient dispensed supplies along with any ward stock or leave or discharge CDs
- patient own medicines (POM)
- unknown substances located on any wards or teams or units across the trust which are no longer required or have expired and cannot be returned to the patient
2 Scope
Pharmacy services staff.
3 Link to overarching policy, and or procedure
- Safe and secure handling of medicines manual
- Controlled drugs (with the exception of St John’s Hospice and RDaSH physical health community services) SOP
- Controlled drugs (St Johns hospice) SOP
- Controlled drugs (RDaSH care groups, community physical health services) SOP
4 Procedure or implementation
The CDs covered by this policy are those covered by schedules 2, 3 (3a and 3b) and 4.
All morphine products other than the lower strength solution (10mg/5ml) are schedule 2 CDs. Lower strength morphine solution 10mg/5ml is a schedule 5 which means that the destruction is to take place on the ward, and it is to be recorded in the ward’s CD destruction book.
All CDs (schedule 2 and 3a) should be recorded in the ward or team CD register as per policy. POMs should be recorded in the back of the register or in the patient own CDs register. Unknown substances should be recorded in the back of the CD register.
No CD register record needs to be made for schedule 3b and 4 CDs.
CDs or unknown substances may only be destroyed on the ward or within the community team by the authorised trained named personnel (ATNP) who is appointed by the trust accountable officer (appendix A) in the presence of a second staff member (counter-signatory).
Schedule 3b (gabapentin, midazolam, phenobarbital, pregabalin, tramadol) and 4 CDs (benzodiazepines, “Z hypnotics”, androgenic and anabolic steroids) are to be quarantined separately in either a sealed envelope or oral syringe with the details of the contents (drug, strength, formulation, quantity and reason for destruction) and placed in a destruction box in the bottom of the drug cupboard to be denatured by pharmacy department and recorded in the ward destruction book.
Please refer to appendix C, at a glance CDs requirements.
All CDs or unknown substances will be destroyed on the ward or team using a proprietary denaturing kit (DOOP), which can be ordered from the SLA pharmacy. The trust pharmacy department will order and store these kits within the pharmacy department.
The pharmacy department has a device available to crush solid dosage forms, the device will destroy the medication in such a manner that they can be dispersed in the DOOP kit. It should not release dust into the atmosphere.
At the point of the patient’s discharge or prior to this, patients own CDs are destroyed, the nurse in charge may ask if an appropriate adult or patient may take the POMs home for storage (the appropriate adult must be approved by the service user and an entry to this effect made in the patient’s clinical records).
If the POMs are no longer required, they should be urged to leave them with pharmacy for destruction rather than run any risk of misuse or misadventure.
4.1 Procedure
- Having received notification from the ward or team, pharmacy staff should liaise with the nurse in charge prior to their visit to:
- ensure that identified stock CDs are no longer needed
- ensure that identified POM CDs are no longer needed, and the patient has consented to the destruction
- check if there are any unknown substances
- The ATNP (who will destroy those CDs or unknown substances) should liaise with the nurse in charge and set a suitable time to come to the ward or team to carry out the CDs destruction.
- On arrival to the ward or team the ATNP should identify themself, with trust identification. They will ask the nurse in charge to accompany them to the treatment room to obtain the CDs or unknown substances to be destroyed, along with the CD register, having assured themselves of the safety of doing so.
- The ATNP and counter-signatory (nurse in charge or pharmacist or RDaSH pharmacy technician if nurse in charge is not able to witness the CD destruction) should get the CDs or unknown substances from the CD cupboard, then lock the cupboard back up and check CDs to be destroyed against the registry entries.
- If multiple destructions are required, this will be done in strict rotation:
- tablets or capsules, remove from packaging, crush and add to DOOP kit
- ampoules, break ampoule, add glass and contents into DOOP kit
- patches, remove packaging, and backing paper, fold the patch in half adhesive side inward and add to DOOP kit.
- liquids, empty directly in to DOOP kit (no more than half full)
- lozenges, remove from packaging and add into DOOP kit. Any excess packaging, for example, plastic stick attached to lozenge, should be cut off to save space in the kit.
- aerosols, expelled under water into a small container, solution to be emptied directly into DOOP kit
- unknown substances, remove from sealed envelope and carry out the destruction as stated above, dependant on the formulation of the unknown substance
- CDs or unknown substances will be signed out of the register as being destroyed, by the ATNP and counter-signatory. A second sheet (appendix B) will also be completed and kept by the trust pharmacy Department.
- The DOOP kit should not be filled more than half full. Once all CDs or unknown substances have been placed in the DOOP kit, it should be filled with water to the fill mark on the label, the lid tightly closed and shaken.
- Once the liquid has formed a gel, the substances are no longer considered as controlled substances, and the container can be disposed of in the pharmaceutical waste bin on the ward or community team.
- The ATPN and counter-signatory should then check the CD register against existing stock and vice versa (except in St John’s Hospice due to the size or range of their CD holding) and if balance is correct then an entry should be made that the stock levels have been checked and are correct, this must then be signed and dated by both the ATNP and the counter signatory. The relevant section from appendix B should be completed accordingly:
- CD cupboards or CD registers checked
- number of items checked
- stock balance and register match
- any discrepancies found, yes or no
- additional comments or discrepancies found
- Any discrepancies must be reported, via the Ulysses Safeguard IR1 system to the accountable officer and ward manager and investigated accordingly.
- All paperwork must be kept for a period of two years from the last entry.
- Audit:
- the form (appendix B) will be used to periodically audit, against the trust CD register books in terms of CD destruction and reconciliation
- the form (appendix B) will also be used for the CD LIN report about how many visits to wards or teams have taken place and how many items have been destroyed
5 Appendices
5.1 Appendix A Pharmacy services staff sign off sheet to be authorised for CD’s or unknown substances destruction by accountable officer
5.2 Appendix B Destruction and reconciliation of CD’s or unknown substances record sheet
5.3 Appendix C At a glance CD’s (1 April 2019)
Document control
- Version: 3.
- Unique reference number: 454.
- Approved by: Clinical policies review and approval group.
- Date approved: 5 April 2022.
- Name of originator or author: Specialist pharmacist.
- Name of responsible individual: Medicines management committee.
- Date issued: 13 April 2022.
- Review date: April 2025.
- Target audience: Pharmacy services staff.
- Description of change: General review with minor amendments.
Page last reviewed: April 24, 2024
Next review due: April 24, 2025