Contents
1 Aim
This standard operating procedure (SOP) represents the practice for safe transcription of medication at new beginnings.
2 Scope
The contents of this procedure are applicable to all staff working in Rotherham, Doncaster and South Humber NHS Trust (RDaSH) new beginnings involved in the transcription or checking of transcription of medication
3 Link to overarching policy
This SOP overarched by and should be read in conjunction with the safe and secure handling of medicines manual (SSHM manual).
4 Procedure
4.1 General
Additional documents may be produced as services develop, regulations change or to reflect changes in the SSHM manual.
- 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 medicines 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 describes the processes in place in a bespoke manner. 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 and so on.)
- where a service’s processes cannot conform to the trust level guidance advice must be sought from the trust pharmacy department
- 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 Modern matron
It is the modern matrons responsibility to:
- review and ensure that the “at a glance” documents forming this SOP have been amended as described above to detail the services 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 amended to detail the revised process and circulated to staff for information and signoff
- ensure adequate stocks drug cards, and other relevant paperwork are available to support continuous adherence to these SOPs
- 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 the trust pharmacy department for support
4.3 Clinical staff members
It is the responsibility of trust clinical 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 Review and version control
The “at a glance” documents that form the basis of this SOP will be formally reviewed every two years. Interim updates will be produced to reflect changes to the SSHM Manual and will be evident through version numbers.
The pharmacy department have responsibility for:
- the formal reviews and generation of new versions resulting from changes to the content of the at a glance documents (with the exception of the right-hand column, which will remain the responsibility of the service or team manager)
- dissemination to teams and intranet availability of the most current version of the SOP
6 Appendices
6.1 Appendix A At a glance, medicine management, New Beginnings
6.1.1 Role, transcription
New Beginnings:
- medicines can be transcribed from one ‘direction to supply or administer’ to another form of ‘direction to supply or administer’
- this should only be undertaken in exceptional circumstances and should not be routine practice
- nursing staff who transcribe are accountable for their actions and omissions
Team specific:
- staff authorised to transcribe are qualified nursing staff.
6.1.2 Role, scenarios where transcription can be used
New Beginnings:
- any act by which medicinal products are written from one form of direction to administer to another is transcribing.
- the transcribed medication information will be obtained from an original direction to administer for example, A and E notes, where new medication has been prescribed and signed by a doctor and patient’s labelled medication
- transcribing is only done in exceptional circumstances and should not be routine practice
Team specific:
- transcribing is not to be used at patient admission or for rewriting whole drug cards
- the prescriber to be made aware that transcribing has been required so that the patient’s treatment can be reviewed
6.1.3 Role, process of transcription
New Beginnings:
- before transcription takes place, the registered nurse must check the patient’s full name, date of birth, drug, indication, dosage (including maximum dose in 24 hours), strength, timing, frequency and route of administration
- the registered nurse must also be clear of the prescribers intended treatment stop date and intended number of doses
- one registered nurse to write up the medication on the prescription chart(s) and sign their name indicating that this medication line has been transcribed
- the transcription is then second checked and countersigned by another qualified nurse or a suitably trained and competent other
- make an entry into the patient’s clinical notes that the medicine (named) has been transcribed including the reason why transcription has been required and document when a prescriber will next review the medication
- any errors or omissions that occur due to transcription require reporting via IR1
Team specific:
- the transcribed details are not a prescription and so cannot be used to order medicines against or for discharge unless countersigned by an appropriate prescriber
- a ‘suitably trained and competent’ other would be a support worker who has completed the trust medicines management training and the transcribing training delivered by the pharmacy department
- the purpose of the second check is to confirm the accuracy of the transcription from an original direction, it is not a clinical check
6.1.4 Role, Links to relevant documents
New Beginnings:
- NMC standards for medicines management 2007
- RDaSH policy ‘The safe and secure handling of medicines’
6.2 Appendix B Medicines management on community services, transcribing
Document control
- Version: 3.
- Unique reference number: 457.
- Date ratified: 3 January 2023.
- Ratified by: Clinical policies review and approval group.
- Name of originator or author: Pharmacist.
- Name of responsible individual: Medicines management committee and pharmacist.
- Date issued: 16 January 2023.
- Review date: 31 December 2025.
- Target audience: New Beginnings.
- Description of change: To add in transcribing.
Page last reviewed: April 24, 2024
Next review due: April 24, 2025