The Registered Nurse in Charge is responsible for the requisitioning of CDs.  The responsibility for ordering CDs can be delegated to another Registered Nurse, however the legal responsibility remains with the Registered Nurse in Charge.   The Registered Nurse in Charge must ensure that access to CD Order Books is restricted to those staff authorised to order CDs.

CDs for stock use must be ordered on a CD Order Book, with a separate page being taken for each order.  The entry must clearly detail:

• The name and location of the service and the date
• Drug name, form, and strength
• Total quantity required in dosage units eg number of millilitres

CDs are delivered as per local standing operating procedure or collected from pharmacy by the Registered Nurse in Charge or deputy and checked and secured as soon as possible upon return to base.  As a matter of good practice and whenever possible the person ordering the medicine should be different to the person receiving the medicine into stock.  This separation of duties creates a robust audit trail.

The receipt of CDs must be checked against the amount ordered and the amount supplied by pharmacy to ensure that all amounts correlate.

The received order must be checked for any discrepancies (if a discrepancy is found it must be reported immediately to the specialist pharmacy technician in the supplying dispensary).

The signature of the recipient on the CD Order Book must confirm receipt.

Details of the receipt of the CD must be entered into the main CD Register as follows:

• There must be a designated page for each medication, form and strength
• Entries in the CD Register must be made in black ballpoint pen.
• The serial number of the order, the date and the quantity received (in words) and the current balance must be entered and signed by the nurse and witness

Storage of CDs must conform to the Misuse of Drugs Safe Custody Regulations, 1973.  For existing or any new CD cupboards or rooms, the Pharmacy Department may be contacted for advice.

Within the department, all CDs must be stored in a locked cupboard, which can only be opened by a person who can lawfully be in possession of the keys, such as the Registered Nurse in Charge or a medical practitioner. General measures for the storage of CDs include the following:

• Cupboards must be kept locked when not in use
• The lock must not be common to any other lock in the premises
• Keys must only be available to authorised members of staff
• No other medicines or items should normally be stored in the CD cupboard
• CDs must be locked away when not in use

The Registered Nurse in Charge is responsible for ensuring that the keys are kept secure when not in use.

If the CD keys go missing, this must be reported immediately to the Registered Nurse in Charge, who must ensure that the following steps are taken as a matter of urgency:

• Ask all staff on duty to check if they have the keys on their person
• Contact staff who have left the premises.  If one of them has the key, they must return it immediately
• Conduct a thorough search of the environment
• If the key remains missing (either assumed lost or with a member of staff unable to return it) then the duplicate key may be issued for use.
• Carry out a full stock check
• If the lock has to be replaced, ensure that the cupboard is not left unsupervised until that has been completed

8.14.8. Patients Own Controlled Drugs

Patients CDs shall be stored in the CD cupboard, segregated from stock

The CDs shall be entered into the patient’s Service own CD register.

A designated page must be used for each medication form and strength for each patient.

The name of the patient should be written on the top of the page with the name of the medication. This page should not be used for anyone else or any other medication.

If this medication is to be destroyed it should NOT be transferred onto another page.

When opioid medicines are prescribed in anything other than acute emergencies, the healthcare practitioner concerned should:

• Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient.  This may be done, for example, through discussion with the patient or their representative (although not in the case of treatment for addiction), the prescriber or through medication records
• Ensure where a dose increase is intended, that the calculated dose is safe for the patient (e.g. for oral morphine or oxycodone in adult patients, not normally more than 50% higher than the previous dose)
• Ensure they are familiar with the characteristics of that medicine and formulation: usual starting dose, frequency of administration, standard dosing increments, symptoms overdose, and common side effects.
  
  

When CDs are prescribed on the TPAR, the written requirements for these medicines are the same as for other medicines:

• Allergies

• Drug name and form

• Route

• Dose

• Frequency (if prescribed “when required” a minimum interval for administration should be specified, e.g. every six hours, and a maximum total quantity to be administered in 24 hours)

• Include a finish date where appropriate

• Start date

• Signature of prescriber
  
  

Controlled Drugs must be prescribed and administered in accordance with local policy and  the NMC Standards for Medicines Management

The healthcare practitioner administering the controlled drug must verify that the appropriate prescription requirements are in place and check appropriate details at the controlled drug cupboard.  Where possible, this should be independently checked (see below) by a second practitioner, or police officer. 

The checks made by the healthcare professional will be:

• Any allergies
• The drug name
• The dose  prescribed
• Route of administration
• Expiry date
• Reconciling balance of stock after removing required quantity of drug against the register balance

Where a second practitioner is not available, a police officer will check:

• The amount prescribed against the amount to be given

• Amount of stock correlates with amount in register

• The medication is given to the person it is prescribed for (witness to the administration) 

It should be noted the police officer is only responsible for the above functions with no clinical responsibility.

The CD register should be completed with the following details:

• Date and time when dose administered  
• Name of patient
• Quantity administered
• Form (name, formulation and strength) administered
• Name/signature and printed name of nurse/doctor administering the dose
• Name/signature and printed name of witness to the administration, or balance of stock in the case of a police officer being the witness
• Balance in stock
• An appropriate record of administration must also be entered on the electronic patient record as well as the TPAR chart

Packaging is not discarded until the patient check has been completed.

The healthcare practitioner must check appropriate patient details.  Where possible, this should be independently* checked (see below) by a second healthcare practitioner.  Checks relate to:

• The name and date of birth stated by the patient corresponds with the details on the prescription.  Where this is not practical (e.g. patients with cognitive impairment), the patient may be identified via other means in accordance with local procedures.
• Confirm the patient is not allergic to the drug
• The correct date and time of administration
• The drug name
• The dose requested is correct in relation to the prescription and is safe for the patient
• The drug details on the original container
• Route of administration
• Expiry date/time

*independently is defined as an individual undertaking the above process on their own without verbal or other communication during the checking process.

This is a three step process, step one is the check at the drug cupboard, step two is the check on administration to the patient, step three is signing of the register after administration.

Administration must be recorded on the electronic patient record and the patient TPAR chart. 

8.14.12. Stocking and maintenance of stock in Perth and Arbroath

When transferring stock to Arbroath and Perth, another person, either another healthcare practitioner or a police officer, should witness each entry into the CD Register. The whole page should be photocopied and returned to Dundee, and filed in the dedicated folder. This will provide an audit trail.

8.14.13. Controlled Drug Stock Checks in Dundee

Stock balance reconciliation will be undertaken every 24 hours.  The Registered Nurse in Charge is responsible for ensuring that this is carried out. In Perth and Arbroath the CDs should be checked when nurses visit. At least once a week these should be checked by two people, the second person being a Police Officer.

Two registered nurses should perform this check.  The staff undertaking this check should be rotated periodically.  The following procedure must be followed:

• Each page of the CD register must be checked against the contents of the CD cupboard, not the reverse, to ensure all balances are checked
• The physical stock of each item should be counted
• It is not necessary to open packs with intact tamper-evident seals for stock checking purposes, e.g. manufacturer's complete sealed packs
• Stock balances of liquid medicines should generally be checked by visual inspection but periodic volume checks may be helpful.  The balance must be confirmed to be correct on completion of a bottle
• A record must be made that the stock check has been carried out and this record must include, as a minimum, the date and time of the reconciliation check and be signed by both members of staff.  See Appendix 7 (main document) for recording form

 Any discrepancy must be investigated in accordance with Section 8.3. Dealing with Discrepancies and the procedure below.

Minor discrepancies in volumes of liquid CDs will be corrected by a Registered Nurse and countersigned by the Nurse in Charge or deputy.  A minor discrepancy is considered to be 5% of the volume contained in the bottle or 10mL, whichever is the smaller volume.

Discrepancies:

In the event of a discrepancy in stock levels, this must be recorded in the same manner and then once the stock levels are reconciled the details must be entered of the circumstances of the discrepancy.  This completes the audit trail.  It is not appropriate, or considered best practice to find a discrepancy and leave the recording sheet blank, but to document this accurately.

In the event of a discrepancy of a controlled drug stock balance, or in the loss of CDs, the Registered Nurse in Charge must investigate the matter, immediately.

• The investigation must include a stock check of all CDs and the content of the record and order books from the cupboard against all controlled drugs received and administered since the previous satisfactory check  
• Check books for discrepancies in entering details, miscalculations of remaining stock or any numerical errors
• Ensure that a controlled drug box/bottle has not been inadvertently placed within another container in the cupboard
• Consider when the drug may have been given, and by whom
• Consider review of electronic records and TPAR charts of patients seen where a controlled drug may have been prescribed and administered
• If no entries are found on the patients TPAR chart or electronically on the patient’s electronic record, then a Datix report requires to be completed as this is in clear breach of standards for recording the administration of CDs.  The report must be tagged as a CD Incident to ensure that it is automatically forwarded to the CD Accountable Officer.
• If none of the above steps result in reconciliation of stock, report immediately to the Head of Service or their deputy

If the error or omission is traced, the Registered Nurse in Charge must make an entry in the CD register clearly stating the reason for the entry and the corrected balance.   Another healthcare professional must witness this entry and both must sign the CD register.

Unused doses, part doses or partly used prepared doses of CDs must be destroyed promptly and witnessed by a Registered Nurse.  The CD to be discarded must be rendered irretrievable by emptying the contents of the bottle, or syringe into a pharmaceutical waste bin (generally blue-lidded).  Liquids should be rendered secure by use of a self-setting compound (such as Pre-Gel or equivalent).  Tablets should be crushed where possible and capsules should be opened prior to disposal. Full details of the destruction must be recorded in the CD register including the names and signatures of those involved.