The Registered Nurse/Midwife in Charge of the ward/department should ensure that sufficient stocks of controlled drugs are available to meet the likely needs of their patients, through ordering adequate supplies during pharmacy opening hours.

In exceptional circumstances, it may be necessary to transfer controlled drugs between wards/departments when the pharmacy is closed. Where possible one dose only should be transferred, provided this is clearly identifiable, for example it may be necessary to transfer a complete or partially used blister strip of tablets. If a patient is likely to require several doses, the minimum stock required until pharmacy opens should be transferred.

Controlled drugs must not be transferred between wards in different hospitals.

Where transfer of controlled drugs is required, the following process should be followed:

1.      Consider whether an alternative drug that is stocked on the ward would be clinically appropriate for the patient. After discussion with medical staff and the nurse in charge a suitable alternative should be prescribed instead if appropriate.

2.      If the medicine is still required, establish where the medicine is likely to be available and telephone to confirm availability.

3.      If the medicine or a suitable alternative is not available in any other ward in the same hospital, the emergency duty pharmacist should be contacted.

4.      If the medicine is available a registered nurse/midwife from the requesting ward will complete Medicines Transfer Form A.

5.      A registered nurse/midwife from the requesting ward should take the patient’s TPAR and the medicine transfer form to the ward holding stock of the required controlled drug.

6.      Two registered nurses/midwives (one from each ward) will then write the stock out of the CD register of the supplying ward, ensuring that the details of the drug are independently checked against the patient’s TPAR and the controlled drug order book. The registered nurse from the supplying ward will confirm the requesting nurse’s identity (for example by checking their name badge). The following should be written in the register:
·         The date and time
·         The patient’s name
·         Amount  transferred
·         The statement “emergency supply to ward……..”
·         Signature of the two registered nurses.
·         Balance in stock

7.      The registered nurse from the supplying ward will sign the “supplied by” column and the registered nurse from the receiving ward will sign the “received by” column on Form A of the receiving wards medicines transfer form.

8.      The registered nurse from the supplying ward must also ensure that the supplying wards Medicines Transfer Form B is completed and countersigned by the registered nurse from the receiving ward.

9.      The registered nurse / midwife from the receiving ward will transfer the stock. Where possible transfer of stock should be witnessed by a registered  nurse / midwife from the supplying ward.

10.    Two registered nurses/midwifes will then write the drug into the controlled drug register of the requesting ward (either one from each ward or two   from the requesting ward). The following should be noted in the register:
·         The date and time
·         The patient’s name
·         Amount transferred
·         The statement “emergency supply from ward……..”
·         Signature of the two registered nurses
·         Signature of the additional witness (if applicable – see point 9)
·         Balance in stock

Nursing staff from the requesting ward should inform their senior charge nurse that they needed to transfer CDs out of hours. The senior charge nurse should consider increasing stock levels of the drug.

The supplying ward must inform their ward pharmacy technician / pharmacist that they supplied CDs to another ward the next working day. The pharmacy technician / pharmacist will check that the transfer has taken place and that the paperwork has been completed correctly. They will then document that this check has taken place by signing on the supplying wards medicines transfer form. 

The supplying ward should arrange replacement of stock as necessary. The receiving ward must NOT return medicines.