Ordering and reconciling desirable drugs

1. Diazepam
2. Dihydrocodeine
3. Lorazepam
4. Nitrazepam
5. Temazepam
6. Tramadol
7. Zolpidem
8. Zopiclone
9. Codeine containing products in areas of high use.

The above list will be subject to regular review. This list represents the core set of drugs that must be scrutinised following this procedure.

Other drugs may be included in the process at the discretion of Senior Charge Nurses or local nurse managers e.g. codeine containing products in areas of high use.

Please note only solid dosage forms (tablets/capsules) are subject to this policy. Liquids and injections are excluded as they are much less likely to be misappropriated.

All drugs from the list must be ordered using the procedure below and stored in the appropriate ward cupboards (which must be locked at all times) when not in use on the trolley, with the following exceptions:

1. Temazepam must be stored in the controlled drug (CD) cupboard at all times.
2. Temazepam & tramadol must be ordered using a Controlled Drug Order book.
3. Of the list above only temazepam must be stored in the CD cupboard. It would be good practice to store other desirable drugs in a separate cupboard or shelf within a cupboard from other drugs.
4 – Pass medications are not subject to scrutiny under this procedure
5 – Patients own drugs are only subject to scrutiny if they are being used to administer prescribed doses to the patient concerned.

1. Wards should only keep a minimal stock of desirable drugs, sufficient to meet the needs of their patients.

2. Wards should only stock desirable drugs that are prescribed and being used, or are likely to be used e.g. lorazepam as required.

3. Desirable drugs will be included on ward stock lists. The total amount required for 7 days should be ordered on this weekly ‘top up’ order.

4. Any desirable drugs required outwith the weekly ‘top up’ must be ordered on a separate pharmacy requisition (indent) from other (non-desirable) medications (See Exception above).

5. Separate requisitions are for unexpected/emergency use e.g. when a new patient is admitted or the prescribed dose has changed, until the weekly amount required is ordered via ‘top up’ again.

6. Each indent for desirable drugs must be short ruled and signed by the nurse in charge of the ward and a second registered member of regular ward nursing staff. When wards have only one registered member of staff on duty, a second signature by a registrant from another ward is acceptable. That nurse must be satisfied there is a genuine need to order the desirable drug(s). To facilitate this they may wish to see the relevant HEPMA entry. If the need is urgent and a second signatory is unavailable, a single signatory is acceptable. It would be good practice for Senior Charge Nurses or their deputy to review orders placed for desirable drugs on a weekly basis.

7. The indent should be sent or scanned and emailed to the appropriate hospital pharmacy for dispensing the original indent should be sent to pharmacy marked ‘sent by email’ with the date and time, as soon as possible.

8. Pharmacy will alert the ward Senior Charge Nurse if they identify any unusual ordering patterns where possible.

9. Once dispensed, the medication will be sent to the ward with the delivery note. Two registered nurses must check the drugs received against this delivery note and the ward copy of the original indent. However, one registered nurse may do this if staffing levels mean two registrants are unavailable. Where possible, the signatory should not be the nurse who raised the order with pharmacy. If everything is correct they should both sign the ‘Received by’ section of the indent and delivery note and file them appropriately. If there are any discrepancies with the order, staff should contact pharmacy immediately. All desirable drugs should be stored securely without delay and any discrepancies rectified as soon as possible.

10. In the event of requiring to borrow desirable drugs from another ward, the ward requiring the medication should show the HEPMA entry to the ward lending the desirable drug to satisfy the lending ward that there is a valid need to borrow. A registered nurse from each ward must sign the medication transfer form.

11. If a ward is unable to borrow the required medication out of hours, the nursing page-holder should be contacted to determine whether a supply is available in any of the emergency cupboards throughout NHSGGC. If not, the out of hours pharmacy service should be contacted via switchboard if the medication is required before pharmacy opens again and if no appropriate alternative can be prescribed.

1. If desirable drugs are no longer required by a ward, contact pharmacy who will advise whether it can be reused elsewhere, returned to pharmacy or destroyed by a member of pharmacy staff in the presence of a registered nurse

2. All wards must reconcile ward stock of desirable drugs once a day by completing Appendix 1, ‘Desirable Drug Reconciliation Form’. These forms once completed should be kept on the ward for 3 months and then discarded. The daily check will:

• Identify the total number of doses (tablets/capsules) of each drug being reconciled
• Highlight any obvious variation from the usage day to day e.g. If the zopiclone balance today is 14 tablets fewer than yesterday and over the previous week the count reduced by 7 tablets per day then nurses would alert the senior charge nurse who would investigate further
• Note: the procedure does not require wards to maintain running balances accounting for every dose administered. The intention is to identify unusual patterns and trigger further scrutiny if they emerge.

3. Any discrepancies found must be reported to the ward Senior Charge Nurse and Lead Nurse as soon as possible. Out of hours the appropriate Response nurse / page holder should be contacted. A Datix report should be completed at ward level. It is the responsibility of management to inform pharmacy and if appropriate the Controlled Drug Accountable Officers team.

3. If any drugs are dropped or unusable for any reason, they should be recorded on the reconciliation from and then immediately destroyed. This must be undertaken by a registered nurse, who will record this following the process described in the SOP for the Safe Disposal of Medication within In-patient Areas.

4. If a partial dose is to be administered (e.g. lorazepam 500 microgram) then the remaining portion of the tablet should be destroyed and recorded on the reconciliation form. This must be undertaken by a registered nurse, who will sign and date the entry on the reconciliation form

5. The Senior Charge Nurse should reconcile and check the ‘Desirable Drug Reconciliation Form’ on a weekly basis and ensure that correct procedures are being followed.(See appendix 2 – Desirable Drug Weekly SCN checklist)

6. This procedure will be subject to regular audit and review. Any failure to comply may result in formal investigation. Annual audits will be carried out as part of peer audit using Appendix 3 ‘Procedure for Ordering and Reconciling Desirable Drugs Audit Form’.