Medicines

Includes the proper and safe use of medicines. Adherence to medicines management policy, appropriate prescribing, administration, documentation, and supply in line with relevant legislation. Storage and robust oversight of CD's and non-CDs within the Trust (on vehicles and station).

YESTERDAY

TODAY

• The Trust must ensure that systems and processes to safely administer, store, prescribe medicines is consistently applied across the trust (Regulation 12).
• The service did not consistently follow safety systems when prescribing, administering, recording, documenting, and storing medication.
• Patient group directives were mostly out of date by approximately one month at the time of inspection.
• CD bag audit forms were inconsistently completed.
• Ambient temperature checks were not performed where medicines were stored.
• Medicine and compressed gas storage facilities on vehicles was secure.
• Good management of medicines related incidents.

• The Trust now has systems and processes in place to safely prescribe, administer, record and store medicines. This is achieved through the new pouch system rolled out trust wide in May 2021.
• All PGD’s are in the process of review by an external provider with a planned implementation date of 31 October 2021.
• The process for CD management changed in 2019 to shift based CD pouches with only LOMs responsible for stock replenishment and auditing.
• At present, several stations have been identified as having concerns around temperature control. Estates are working with the medicines management team to rectify any areas of non-compliance.
• The Trust continues to spot check security around the storage of medical gases and medicines on trust property and vehicles.  
• The Trust continues to manage medicines related incidents in a robust manner through use and review of Datix trust wide.

TOMORROW

• The medicines management policy is currently under review. The roll out of the new ePCR will assist with real time audit of compliance with the prescribing, administration and recording of medicines going forward.
• Plans include the provision of electronic access for staff to all PGDs to allow timely dissemination and access to information.
• The Trust continues to monitor CD stock levels at local levels. Audits demonstrate an improvement in compliance of CD management to over 90% in all areas.
• The medicines management team will continue to review and monitor ongoing temperature control throughout trust premises and vehicles.
• In the future, the medicines management team are hoping to make use of a medical gases tracking system to enable oversight of stick and minimise loss of cylinders.
• Whilst the medicines management team have noted an increase in the number of medicines related incidents, harm remains low. The team will continue to identify and monitor themes and trends, taking relevant action where required.