8.9.1. Transport of CDs

CDs must be transported in a secure, sealed, tamper evident container by porters and transport staff. CDs must not be transported in pneumatic tubes or posted.

CD prescriptions can be posted via recorded delivery.

Nurses should not routinely transport Controlled Drugs between Wards in the course of their practice.  This must only be undertaken in circumstances where there is no other reasonable mechanism available. During transport all drugs must be kept out of sight. Where porters are unavailable or the order is urgent, an appropriate member of the Ward/Department staff must uplift the request and transport back to the Ward. Pharmacy staff must only release a CD order to a member of staff with appropriate photographic ID.

At each point a CD moves from the authorised possession of one member of staff to another, a signature for receipt must be obtained alongside the tamper evident ID tag on the container. When transferring CDs between Wards/Departments, the Ward Transfer Form must be used.

Two copies of this form must be completed and one copy kept within each Ward/Department (Photocopies not permitted). Completed Transfer Forms must be archived alongside archived Controlled Stationery.

If Controlled Drugs have to be delivered by a taxi driver they must be packaged within a tamper evident container.

It is good practice for the Ward / Department receiving the CDs to inform Pharmacy of receipt.

8.9.2. Patient’s Home

The nurse must sign and check the stock in the Patient Drug Record Card, and it should be witnessed that the CD has been received by the patient.  Where a second nurse is not available another competent person may witness receipt, for example, a family member.

Advice should be given to patient’s regarding how to store CDs safely in their home and the process for disposal of any unused CDs (return to Community Pharmacy) by the patient, patient’s family member or family care (if appropriate).

Nurses and GPs may remove CDs and return them to a Community Pharmacy for disposal when adverse situations may occur:

·         Family members are known substance users

·         Where the property is being left unattended and there is a significant risk of theft

·         If there is no carer/relative able to return drugs to Community Pharmacy.

Should the GP remove the CDs for CD Destruction, the GP must record the transfer and destruction of the Patient CDs in the Practice or their Personal CD Register. In line with good practice, the Destruction of the Patient’s CDs should be witnessed by another member of staff.

8.9.3. Transfer of CDs between Wards/Departments when Pharmacy is Closed

Senior Charge Nurse/Midwife/Operating Department Practitioner of the Ward/Department / Theatre should ensure that sufficient stocks of CDs are available to meet patient demand through ordering adequate supplies during Pharmacy opening hours.

CDs must only be obtained from Pharmacy. In exceptional circumstances, where a patient urgently needs a CD which is not available in the patient’s own clinical area or where an appropriate alternative is not available in the patient’s own clinical area and the Pharmacy is closed, Senior Charge Nurse/Midwife/Operating Department Practitioner must be asked to authorise the administration of drugs from another clinical area. They must exercise their professional judgment; the wellbeing of the patient being the main consideration.

Stock must be transferred between Controlled Drug Registers.

Transfer of CDs Form

8.9.4. Transfer of CDs Process

Individual doses of CDs may be obtained under the following circumstances:

·         The nurses in charge of both areas agree

·         The Ward, theatre or Department that holds the stock is nearby to the borrowing Ward, Theatre or Department.

·         Complete a CD Transfer Form

·         It is anticipated that no more than 2 doses will be required otherwise consideration must be given to contacting the on-call Pharmacist as soon as possible to establish a new supply if this is more appropriate or wait to obtain the next day from Pharmacy.

·         The dose must be transferred at the time it is required

CDs must not be transferred between Wards / Departments in different hospitals, unless during exceptional circumstances. Refer to local policies.