Second Checking of Controlled Drugs in Community Hospitals and Mental Health Units

For the administration of Controlled Drugs (CD’s) where possible the staff undertaking the whole process from selection of the drug to administration should be 2 registered staff members.

NHS Borders Code of Practice for the Control of Medicines policy states that this may be a registered nurse, midwife, doctor or ODP. However, in a community hospital/mental health ward setting it is recognised that there are frequently occasions (i.e.: night shift) where there is only one registered nurse on duty. In these circumstances in order to ensure that patients are administered their CD’s in a timely manner then Health Care Support Workers (HCSW’s) that have completed relevant training can act as a witness for the preparation and administration of controlled drugs.

This should only be in circumstances when there is not another registered nurse available and should not become standard practice.

Two RN’s to administer CD’s is always the preferred option. When there is not another RN on duty however, using a trained HCSW is considered to be a safer option than a single nurse check.

For the administration of controlled drugs single nurse checks must not be considered. NHS Borders Code of Practice for the Control of Medicines policy does not cover single nurse checking so it would be a breach of policy if a nurse opted to administer a controlled drug without a witness.

When asking HCSW’s to act as a witness the RN must be assured that the HCSW has completed all relevant training and are competent and confident in the task. It is the responsibility of the senior charge nurse (SCN) to ensure that HCSW’s have completed relevant training.

The relevant Learn pro unit ‘Controlled drugs HCSW’s’ is available via NHS Borders intranet site. This must be completed by the HCSW before they can undertake the role as second checker.

HCSW’s role in relation to CD’s

• HCSW’s may act as a witness to RN to receive controlled drugs from pharmacy/patient into stock.
• HCSW’s may act as a witness to RN to perform daily stock checks as per NHS Borders Code of Practice for the Control of Medicines policy.
• HCSW’s may act as a witness to RN for the preparation and administration of CDs to a patient but only when there is no other RN available to act as a witness.
• HCSW’s must only be asked to verify that the correct drug has been selected, the correct form, route and that the amount remaining in the cabinet matches the amount in the CD (Controlled Drug) register/Omnicell cabinet.
• The HCSW must not be asked to verify any calculations to achieve a dose.
  * See flowchart and note below.
• HCSW’s must witness the drug being given to the patient by the RN. As the registered member of staff, it must be the RN that administers the drug to the patient witnessed by the HCSW and not the HCSW witnessed by the RN.
• When the HCSW signs the ward register they should sign their name and write ‘witness.’ This then gives a clear record that the drug was administered by the RN as per NHS Borders policy.

HCSW’s that are required to act as a witness for the administration of CD’s are not responsible or accountable for knowing the therapeutic uses, doses and side effects of the drugs administered to patients.

The RN is the accountable member of staff when a HCSW is required to act as a witness for the administration of controlled drugs.

 * If a calculation is necessary i.e.: syringe driver/infusion and there are no other registered staff on shift to check the calculation then the nurse must document in the CD register/Omnicell notes ‘No RN on duty to check the calculation.’

If the RN is unsure of the calculation and requires a second check, then they can contact Borders Urgent Care Centre (BUCC) on 01896 Crisis Team Charge Nurse or the on-call Pharmacist via NHS Borders switchboard 01896 826000.

BUCC staff and the on call pharmacists must be able to see the Kardex or paperwork for syringe driver checks, they will need to be scanned/e-mailed to the appropriate clinician for review.

The preparation of syringe drivers should be planned so they are made up when there are two RNs available. This may involve them being prepared in advance of the shift ending to prevent and reduce the requirement for syringe drivers to be changed overnight. ensuring that there are 2 RN’s available for the entire process.