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SAFE AND SECURE HANDLING OF MEDICINES

Section 8.3: Incidents, Near Misses and Concerns

8.3	Controlled Drugs - general prescribing information: Incidents There is a legal requirement for the CD Accountable Officer (CDAO) to be notified of all incidents and concerns involving CDs.
8.3.1	All incidents involving CDs must be recorded and investigated by local management and reported on Datix in line with existing procedures for clinical or medication incidents.
8.3.2	All CD Incident Reports must include details of the actions taken, including immediate steps to prevent or reduce harm to patients, any investigations undertaken and actions taken to prevent recurrence, to provide an assurance to the CDAO that the incident has been thoroughly investigated.
8.3.3	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 CDAO Team.
8.3.4	Any concerns regarding the management or use of CDs must be raised with the CDAO. All concerns will be treated in the strictest confidence regardless of whether the subsequent review substantiates these concerns. All investigations will be carried out in a discrete manner.
8.3.5	In the case of serious incidents or concerns, appropriate support will be provided to any investigation.
8.3.6	In the event of a serious incident or any concern, the CDAO or Head of CD Governance must be notified directly (within normal working hours) via (01382) 835153 (internal 71374) or cdteam.tayside@nhs.net
8.3.7	Where there is suspicion or evidence of criminal activity, Tayside Police may also require to be notified. See Section 30.
	Examples of CD Incidents and Concerns 1. Clinical Governance and Professional Practice All events or near misses involving prescribing, administration, supply or dispensing of CDs. Any concern(s) about professional practice or behaviour of staff in relation to CDs e.g. unusual prescribing patterns. Complaints from patients/carers/service users relating to CDs. 2. Record Keeping and Stock Discrepancies Unexplained losses/discrepancies of any CD, regardless of schedule. Any discrepancy in CD stock which, although resolved, raises concerns. Events or near misses involving CD destruction. Loss of CD Register/Order Book or other relevant controlled stationery. 3. Fraud and Possible Criminal Issues Any suspected illegal activity relating to CDs e.g. theft, patients attempting to obtain CDs by deception. Lost or stolen prescription forms. Attempts to fraudulently produce prescriptions. These examples are not mutually exclusive, for example, record keeping issues may escalate to concerns about clinical practice or suspected theft.