Updates to medicines management policy

Patient-facing colleagues are asked to familiarise themselves with the Medicines management policy (click on the link to visit the medicines management page, where the policy is) which has been updated with a few minor changes.

These include updates to:

2.0, authority to possess and supply (page 39):

• Paramedics and nurses should have only one individual record book (red book), all others should be returned to the medicine management lead.
• Auditing of controlled drugs has equal responsibility for managers and paramedics/nurses. Staff should inform a manager if they have not had an audit conducted within the timeframe of the medicine management policy.

3.0, ordering controlled drugs (page 39):

Individually issued morphine  supplies for paramedics shall only be obtained through the agreed supply route for the locality:

• Via the DLO from station stock: the individual stock level will be brought up to five ampoules
• Via a hospital pharmacy: the maximum holding will be 12 ampoules, which takes into account that some pharmacies will only issue boxes of 10 ampoules.

4.0, storage of controlled drugs (page 41): 

• Paramedics will store their individually issued stock of morphine in a personal Trust drug safe at an ambulance station, to which only they hold the key on their person, or a drugs safe in a Trust vehicle when they are on duty, to which they must hold the key.

• Individually held controlled drugs must be returned to a station with a suitable individual safe if the medication will not be used for more than 96-hours (i.e. not predictably attending work).

Paramedics and nurses, including managers, will need to be authorised to use controlled drugs and to have the need to transport these between locations. All effort should be made to reduce the need to hold medication outside of work time. This includes discussion with your line manager on storing at a station closer to home than your base/administration base. In addition, for staff working at alternative locations, additional wall mounted safes can be made available. This should be discussed with your line manager.

• Where morphine is approved to be held outside of work then the following applies:

• It should be secured in a locked Trust-approved container
• Removed from your car at night
• Stored in a discreet location away from extremes of temperature, children and pets
• Not held there for any longer than required and no more than 96-hours.

6.0, control and record keeping (page 44)

All controlled drug stocks, whether in date or awaiting disposal, should be audited by an authorised manager every day where practical, preferably in the morning. The check will be recorded on the Daily drug check form for the store. Any anomalies shall be immediately notified to a senior locality manager, who will instigate investigation and decide on any action to be taken.

Audit processes

A number of changes have been made to the medicines management audit process, which is of particular relevance to duty locality officers and senior locality managers. This includes changes to the:

• Medicines Management Assurance Proforma (MMAP)
• storage of POMs at station and in drug bags
• station storage of CDs, both in-date and out-of-date stocks
• destruction of drugs
• individual controlled drugs record books (‘red/green/blue books’).

Now, for all above, audit spreadsheet evidence has to be uploaded to HealthAssure and sent to medicinemanagement@eastamb.nhs.uk and clinical.leads@eastamb.nhs.uk.

You can download a copy of the policy to read on East24, but if you have any questions please don’t hesitate to email medicinemanagement@eastamb.nhs.uk.

Published 19th April, 2016