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SAFE AND SECURE HANDLING OF MEDICINES

Section 8.2: Dealing with Discrepancies

8.2	Controlled Drugs - general prescribing information: Dealing with Discrepancies
8.2.1	The balances in the CD register must always tally with the amounts of CDs in stock. If they do not, the discrepancy must be fully investigated as soon as possible. In the first instance the following should be carefully checked: Arithmetic since last correct balance. Re-check CD cupboard or GP bag with second person (remember to include date expired stock and exclude patient returns which may have become mixed with stock). Other register sections of same drug class for erroneous entries. Other holdings, eg GP bags for stock which may have been transferred but not recorded. Sense-check register (correct pack sizes, patterns of entry for potential missing entries, and unusual quantities). All orders have been entered by checking delivery notes/invoices/stock orders for discrepancies. All CDs administered have been entered into the register. Check diary and contact all relevant practitioners who have worked at the ward/clinic/department during the relevant period to verify any supplies made that may have not been entered or been entered erroneously.
8.2.2	If the error or omission is traced, the healthcare professional in charge must make an entry in the CD register clearly stating the reason for the entry and the corrected balance. This entry must be witnessed by another healthcare professional and both must sign the CD register.
8.2.3	If the discrepancy cannot be resolved, the healthcare professional in charge must make an entry in the CD register clearly documenting the discrepancy, (including the actual balance) and stating that this is under investigation. The entry must be witnessed by another healthcare professional and both must sign the CD register. The line/duty manager and Pharmacist must be notified (within normal working hours) and the discrepancy handled in according with Section 8.3.
8.2.4	A Datix Report must be completed. All Incident Reports involving a CD must be tagged as a CD Incident on Datix to ensure that the report is automatically forwarded to the CD Accountable Officer.