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13.1	Medicines should normally be ordered from the Pharmacy Department during the working hours. When the Pharmacy Department is closed a service will be provided by local arrangements involving limited extended hours service or an emergency duty pharmacist. An emergency medicines cupboard is located in several hospitals. Access to the cupboard is controlled by locally authorised persons to whom requests for medicines must be addressed. Exceptionally and outwith Pharmacy hours, arrangements may be made to transfer medicines from another ward. All details of these transfers must be recorded by the receiving and supplying ward on their respective copy of the Medicines Transfer Form. Staff should be alert to the accessibility of Attractive/Desirable medicines highlighted in Appendix 6. If there are any concerns at increased stock use or levels of borrowing this should be escalated to the senior charge nurse and Pharmacist in working hours and to the Duty Bleep Holder out of hours. A copy of each medicines transfer form is given in Appendix 2: Form A - record of requesting/receiving medicines and Form B - record of supplying medicines.
13.2	Medicines required out of hours: Transfer of medicines in hospital (see Section 8.11 for transfer of controlled drugs):
	Confirm with the prescriber that the medicine must be administered before the Pharmacy re-opens and discuss the need to transfer medicines with the nurse in charge.
	Procedure: Transfer of medication within the hospital
	(a)	Establish where the medicine is likely to be available by accessing the stock locator file on staffnet and telephone to confirm availability.
	(b)	If the medication is available then a registered nurse from the requesting ward will complete Ward Medicine Transfer From A.
	(c)	A member of staff will take the patient's TPAR and the medicines transfer form to the ward holding stock of the required drug.
	(d)	A registered nurse from the supplying ward must check the patient's TPAR and the information on the medicines transfer form with the messenger from the requesting ward. The registered nurse from the supplying ward will confirm the requesting staff member's identify (for example by checking their name badge).
	(e)	Complete pack(s) of medicines should be supplied where possible.
	(f)	The registered nurse from the supplying ward will sign the "supplied by" column and the messenger will sign the "received by" column on From A of the receiving wards medicines transfer form.
	(g)	The registered nurse from the supplying ward must also ensure that Form B of the supplying wards medicine transfer form is completed and countersigned by the messenger from the receiving ward.
	(h)	The messenger from the requesting ward will return with the medicine, the medicine transfer form and the patient's TPAR.
	(i)	Transfers must be recorded in the same form for that month. The transfer forms should be stored in a designated area in the ward for 2 years (e.g. in a specific folder or section of a folder). Senior Charge Nurses must review these forms on a regular basis. Pharmacy staff will also review the forms as part of the 3 monthly controlled drug check.
	(j)	The supplying ward must arrange replacement of stock. the receiving ward must NOT return medicines.
	(k)	The above procedure applies only when pharmacy is closed. If medicines cannot be transferred, the Nurse in Charge of the requesting ward must contact the emergency duty pharmacist.
	Procedure: Transfer of medication to other hospitals
	Transfer of medication between wards in different hospitals should only occur when absolutely necessary and after discussion with medical staff and the nurse in charge. Controlled Drugs must not be transferred between wards in different hospitals.
	(a)	Establish where the medicine is likely to be available by accessing the stock locator file on staffnet. The requesting ward must then contact the identified wards to confirm availability of the medicine.
	(b)	If medication is available then a registered nurse from the requesting ward will complete the Ward Medicines Transfer Form A.
	(c)	The requesting ward is responsible for organising transport to collect the medication.
	(d)	The Nurse in Charge of the supplying ward must ensure that the Ward Medicines Transfer Form B is completed and arrange for a duplicate copy to be sent with the medication.
	(e)	The medication must be securely transported using an envopak or other suitable means, as described in Section 10.4.
	(f)	On receipt of the medication and the duplicate copy of Ward Medicines Transfer Form B the requesting ward must complete the supplied by column on the Ward Medicines Transfer Form A (Form A should be attached to Form B as a permanent record). The Nurse in charge must then contact the supplying ward to confirm that the medicines have arrived.
	(g)	Transfers must be recorded in the same form for that month. The transfer forms should be stored in a designated area in the ward for 2 years (e.g. in a specific folder or section of a folder). Senior Charge Nurses should review these forms on a regular basis. Pharmacy staff will also review the forms as part of the 3 monthly controlled drug check.
	(h)	The supplying ward should arrange replacement of stock. The receiving ward should NOT return medicines.
	(i)	The above procedure applies only when pharmacy is closed. If medicines cannot be transferred, the Nurse in Charge of the requesting ward should contact the emergency duty pharmacist.