The following procedure should be followed to order pass medication for patients:

Step 1

Document in EMIS the duration of the pass plus any requirement for ‘as required’ medication.

Step 2

Complete the first two sections of the pass medication request form in full. This may be done by nursing, pharmacy or medical staff, who should sign the form appropriately.  Include details of any 'as required' medicines need plus any special requirements e.g. compliance devices.

It is expected that the ward will supply items such as inhalers, eye-drops, creams and insulin as necessary. Consideration needs to be given as to whether they have sufficient supplies of such items to cover the duration of the pass. Any items required should be indicated on the pass medication request form.

If the pass is to be repeated, a new pass medication request form will need to be completed for each episode of leave (common for Learning Disability and Forensic patients).

Step 3

When sections 1 & 2 of the Pass Request Form have been completed, the form should be scanned and emailed to the appropriate generic pharmacy email address. 

Where there is an onsite dispensary, the form may be taken to pharmacy.

Step 4

Pharmacy staff will access HEPMA and print off the MAC to dispense the prescriptions.

Pharmacy will dispense the patient’s medication and complete in full the pharmacy section of the Pass Medication Request Form.

Step 5

The dispensed pass medication and a copy of the completed form will be returned to the ward where it will be stored appropriately until required by the patient.

Step 6

Prior to issuing the pass medication to the patient, a qualified nurse must check the contents of the pass supply against the Pass Medication Request Form and the HEPMA prescription. The purpose of this check is to pick up any dispensing errors or identify any changes to the patient’s prescription that may have taken place since the pass was ordered. Any discrepancies must be notified to pharmacy immediately and if necessary a new pass medication request ordered using the procedure above. If everything is correct the nurse must sign and date section 4 of the form.

Step 7

On handing the pass medication supply to the patient or their representative a signature must be obtained. The Pass Medication Request Form should then be filed appropriately in the patient’s notes.

A HEPMA user with appropriate permissions should suspend all meds using ‘All Orders’ in ‘InpatientRx’, selecting ‘Short Term Leave’ as the reason. If a patient has had a drug suspend for clinical reasons before going on pass add a patient note saying, ‘Patient on pass {add name of the drug} suspended for clinical reasons prior to pass, review by doctor on return’.

Section 4 in request form should be completed to confirm that medications have been suspended.

Upon the patients return, ‘All Orders’ should be used to resume all meds. However, this will resume all medicines including any which may have been previously suspended for clinical reasons. Therefore, if this applies ask a doctor to review the relevant medicine when the patient returns.

Exceptions

1. Controlled Drugs – The system above may be used for any non CDs on the patient’s prescription. However, CDs required for the pass must be ordered on a separate prescription, compliant with the relevant legislative requirements and written by an appropriate prescriber.

2. Local policy must be followed for any passes dispensed out with normal pharmacy hours.

The form for ordering pass medication can be found here.