St Gemma'S Hospice Policies And Guidance Page 11
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19St Gemma’s Hospice
weekend, who will organise an investigation and an incident form (not an error form) is
filled in and inform the hospice pharmacists on their next working day. Incidents and
errors relating to controlled drugs must be reported to the Healthcare Commission by
the Director of Nursing.
5.15
Ph checks the balance of CD records every three months and a record is kept of this
check in the CD book. A controlled drugs report form is also completed.
5.16
Pharmacy technical staff make quarterly checks for out of date drugs, highlighting short
dated drugs (less than three months) with a sticker to alert staff.
Expired stock CDs are entered in the STOCK CD register on the “CDs awaiting
5.17
destruction” page and are removed by the Home Office Authorised person.
5.18
A line is left between all entries on the drugs for destruction, removal or return to
patients’ pages.
If required, patients’ own CDs are returned to a patient on discharge and signed out of
5.19
the register or Oramorph 10mg/5ml and temazepam book by two RNs
5.20
If a RN leaves the building with the drug keys the ward co-ordinator contacts a member
of HLT or the manager on call to obtain a spare set of keys from the key safe on the
moors ward. The RN is contacted and asked to return the keys immediately not when
next on duty. Co-ordinator requests HLT member to return spare keys to safe.
6
Procedure
6.1
RN checks label of medicine for any specified storage conditions.
6.2
When a patient dies or is discharged RN removes all medication from patients lockers
see 8.1 and 8.2 below.
.
RN or Ph places these in the “drugs to return to pharmacy” box, these are kept for
6.3
seven days.
Two RNs and/or Ph check balance and bag up CD’s not in current use (one product in
6.4
each bag) and seal with a tamper proof seal, recording balance and seal number, date
and signature of both person making entry and witness in the CD book, on the page in
use for that product in order for the CD not to be measured or counted each 24 hour
period.
Section 3 - Disposal of Medication
7
Preamble
7.1
All medicines are disposed of as per:
“The Hazardous Waste (England and Wales) Regulations 2005”
“Environmental Protection (Duty of Care) Regulations 1991”
The ‘Special Waste Regulations 1996’ have been replaced by the ‘The Hazardous
Waste (England and Wales) Regulations 2005’.
Page 11 of 19
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