dispensary standard operating procedures -...

Dispensary Procedures: Standard Operating Procedure SI MAN 101Date of preparation: August 2014

Dispensary Standard Operating Procedures

1

2014

2014

2014

2014

Title Dispensary Procedures: Standard Operating Procedures SOP number S1 Man 001 Issue date August 2014 Implementation August 2014date Review date August 2014 Purpose To define the procedures for the safe and accurate dispensing of medication by providing a consistently professional service to our customers. Scope The procedures set out in this Standard Operating Procedure apply to all employees involved in the dispensing process.

Name & Title Signature Date

Written by Rajinder Henderson Professional Standards Pharmacist

Approved by Rita Patel Business Performance Manager Victoria Steele Head of Clinical Governance and Professional Standards/Deputy Superintendent Authorised by Steve Howard Superintendent Pharmacist


Contents

2

Introduction

The Responsible Pharmacist ............................................................................................................................................................................................................................................. SOP 1

Prescription Reception .................................................................................................................................................................................................................................................................. SOP 2

Pharmaceutical & Legal Assessment ................................................................................................................................................................................................................ SOP 3

Selection, Labelling and Assembly ........................................................................................................................................................................................................................ SOP 4

Prescription Owings ........................................................................................................................................................................................................................................................................... SOP 5

Accuracy Check ......................................................................................................................................................................................................................................................................................... SOP 6

Bagging Up ........................................................................................................................................................................................................................................................................................................ SOP 7

Prescription Transfer .......................................................................................................................................................................................................................................................................... SOP 8

Interventions and Problem Solving ........................................................................................................................................................................................................................ SOP 9

Delivery of Prescriptions .............................................................................................................................................................................................................................................................. SOP 10

Fridge Temperature Monitoring ................................................................................................................................................................................................................................. SOP 11

Controlled Drugs in the Pharmacy: Access, Storage, Dispensing and Reordering ...................................................................................................................................................................................... SOP 12

Stock Checks and Using Running Balance Registers for Schedule 2 Controlled Drugs (CDs) ...................................................................................................................................................................................................................................................................................................................... SOP 12.1

Handling and Destruction of Patient Returned Controlled Drugs ....................................................................................................................................................................................................... SOP 12.2

Disposal of Out of Date/Obsolete Pharmacy Stocks of Schedule 2 Controlled Drugs by an Authorised Witness (AW) ....................................................................................................................................................................................................................................................................... SOP 12.3

Supply of Schedule 2 & 3 Controlled Drugs on a Requisition ........................................................................................................................................................................................................................... SOP 12.4

Appendix - Reducing Dose Errors With Opioid Medicines ......................................................................................................................................................................................................................................... SOP 12.5

Dispensing EEA (European Economic Area) and Swiss Prescriptions ..................................................................................................... SOP 13

Veterinary Prescriptions ............................................................................................................................................................................................................................................................. SOP 14

Chronic Medication Service (CMS) (Scotland Only) ............................................................................................................................................................... SOP 15

Urgent Provision of Repeat Medicines and Appliances (Scotland only) ........................................................................................... SOP 16

Patient Returned Medication .......................................................................................................................................................................................................................................... SOP 17

Repeat Dispensing (Excludes Scotland and Northern Ireland) ......................................................................................................................... SOP 18

Support for Self Care, Signposting and Health Promotion ....................................................................................................................................... SOP 19

NRLS ............................................................................................................................................................................................ SOP 20

NRLS: Supply of Lithium .................................................................................................................................................................................................................................................................................................................................................................................. SOP 20.1

NRLS: Supply of Anticoagulation Medicine ................................................................................................................................................................................................................................................................................................... SOP 20.2

NRLS: Supply of Methotrexate ........................................................................................................................................................................................................................................................................................................................................................ SOP 20.3

NRLS: Supply of Insulin to Adults ............................................................................................................................................................................................................................................................................................................................................. SOP 20.4

Electronic Transfer of Prescriptions (ETP) – electronic Acute Medication Service (eAMS) (Scotland only) ......................................................................................................................................................................................... SOP 21

Customer Complaints ................................................................................................................................................................................................................................................................... SOP 22

Care Homes ..................................................................................................................................................................................................................................................................................................... SOP 23

Community Dosage Systems .......................................................................................................................................................................................................................................... SOP 24

Supporting Guidance ..................................................................................................................................................................................................................................................................... Guidance

14

Dispensary Procedures: Standard Operating Procedure SI MAN 101 Date of preparation: August 2014

Introduction

3

Purple Sections

The information in the purple boxes defines the the objectives, risk and scope of the SOP, it also details when the SOP will be reviewed.

Amber Sections

The procedures which MUST be adhered to as directed by the Pharmacy Superintendents Office (PSO) are contained in the amber boxes.

Green Sections

The practice guidance is contained in green boxes, this is intended to support the information in the SOP.

White Sections

The information in the white boxes contains the appendix, this is additional information to support the delivery of the SOP.

For further guidance please refer to:

❚ “Risk Reduction in your Pharmacy” available on Documents on Demand or from the Pharmacy Superintendent’s Office (PSO), Support Centre, Coventry CV2 2TX.

❚ “Standards for owners and Superintendent Pharmacists of retail pharmacy businesses” available from the GPhC.

In order to comply with Clinical Governance requirements, healthcare professions are required to put in place strategies for risk minimisation and harm reduction.

From 1 January 2005, the Royal Pharmaceutical Society introduced the requirement for Pharmacy Superintendents to have in place written Standard Operating Procedures (SOPs) as part of the process of assuring good Clinical Governance in pharmacy. Developing and working with SOPs ensures that the provision of pharmacy services will be safe and effective and facilitate improvement.

The Health Act 2006 requires by law that every registered pharmacy premises has a Responsible Pharmacist (RP) in charge to ensure the pharmacy operates safely and securely when dispensing, selling and supplying medicines. To comply with the Responsible Pharmacist Regulations, the RP has a statutory duty to make sure Standard Operating Procedures (SOPs) are in place which allow the safe and effective running of a pharmacy.

This guidance was reiterated by the General Pharmaceutical Council (GPhC) who assumed the role of the regulatory body for Pharmacists, pharmacy technicians and pharmacy premises in September 2010.


4

Information Governance

Further InformationFor further information about Information Governance please refer to the IG Toolkit on OnePortal and the IG Folder in the pharmacy.

Following the Caldicott Review (1997) into the ways patient information is used to ensure confidentiality is not undermined; recommendations to strengthen information governance were introduced.

Information governance covers accuracy of data, patient confidentiality and consent.

The purpose of maintaining accurate data is to minimise clinical risk and support the provision of high quality care by promoting the effective and appropriate use of information.

Freedom of Information Requests:

Please forward to the Pharmacy Superintendent’s Office (PSO) immediately as the response must be made within defined timescales.

Accurate data can help you to:

❚ Minimise the chance of a dispensing error occurring. ❚ Provide good customer service. ❚ Minimise the level of owings. ❚ Maintain accurate stock levels – making the dispensing process easier. ❚ Allow controlled use of the data by other applications e.g. PSA.

The following areas with the dispensing system need to contain accurate data:

❚ Patient name ❚ Patient address ❚ Patient date of birth (DOB) ❚ Patient postcode ❚ Patient gender ❚ Prescriber information ❚ Stock levels ❚ Care home information

Entering the postcode and the date of birth in to the dispensing system is now mandatory for all patients.

Practice GuidanceIt is essential that care is taken when entering new patient records within the PMR in order to avoid duplicate records being created. Such duplication of records can lead to a disruption in the continuity of individual patients Electronic Health Record (EHR) such that the level of care provided to the patient could be seriously compromised.


5

Confidentiality

Patients have the right to expect that information obtained about them is kept confidential and is used only for the purposes for which it was given. This applies to every member of the pharmacy team.

Confidential information (information that can identify individual patients) includes:

❚ Personal details: Name, Address, DOB. ❚ Information about a patient’s medication. ❚ Information about a patient’s medical history or care.

Third Party Requests for Confidential Patient Information:

Confidential information must only be disclosed for non healthcare purposes with the explicit consent from the patient or unless there is a legal basis, a robust public interest or legal justification.

Any requests for patient confidential information should be directed to the Pharmacy Superintendent’s Office (PSO) via telephone: 024 7662 5454 option 1.

Information should not be given out to a third party without express permission of the PSO, unless the Responsible Pharmacist deems it absolutely necessary that the information is required in an emergency. In this instance, contact the PSO after the event.

Further Information

Guidance on maintaining the confidentiality of patient data/information is contained in the booklet “A Guide to Confidentiality in Your Pharmacy” which all staff should have read and signed the declaration section. Further information is available from the Pharmacy Superintendent’s Office (PSO), Support Centre, Coventry CV2 2TX.


6

Implementation of SOPs and Compliance

It is the responsibility of the Pharmacy Manager (Pharmacist), or in their absence, the Pharmacist or Pharmacy Manager (non-Pharmacist), to ensure that each member of the pharmacy team receives training on the relevant SOPs that they will be expected to undertake within the pharmacy.

Members of the pharmacy team must not carry out the tasks identified/defined within the SOPs unless they have been trained to do so and signed the relevant section of the Record of Competence to indicate that they have read and understood the information within the SOP and will comply with the SOPs at all times. An authorised person must also complete the Record of Competence indicating the employee has received the necessary training within the relevant SOP. This is necessary to comply with Clinical Governance requirements which state that in order to minimise the risk of an adverse event occurring, only competent and trained members of the pharmacy team should carry out a procedure. This safeguards the public from unnecessary risks and provides care that is of the highest standard.


7

Guidance: Record of Competence

This record must be completed and stored in your Dispensary SOPs folder as it is required as proof of compliance with SOPs by the Primary Care Organisation (PCO) and General Pharmaceutical Council (GPhC).

A separate Record of Competence must be completed for each individual member of the pharmacy team including the Pharmacist and must include the following details: ❚ Employee name ❚ Employee number ❚ Employee job title ❚ The relevant qualifications of the employee ❚ Signatures corresponding to the “Name of SOP” for which the individual has signed to declare their competency in carrying out the task as identified within the SOP

❚ Date on which the Record of Competence was signed

By signing this declaration you are confirming that: ❚ You have received the necessary training as outlined within the relevant SOP ❚ You have read and understood the information within the relevant SOP ❚ You will comply with the SOP at all times

The authorised person must also complete the Record of Competence and must include the following details: ❚ Name ❚ Signature ❚ Date on which the Record of Competence was signed

By signing this declaration you are confirming that: ❚ The employee identified within this Record of Competence has received the necessary training outlined within the relevant SOP

❚ You are satisfied that the employee is competent to undertake the task identified within the relevant SOP

The responsibility for reviewing the Record of Competence rests with the authorised person. The authorised person is the Pharmacy Manager (Pharmacist), or in their absence, the Pharmacist or Pharmacy Manager (non-Pharmacist). In the absence of these members of staff, the appropriate Field Manager will be responsible for review. The authorised person signing the Record of Competence for Pharmacists must be the appropriate Field Manager, the Area Manager.

The Record of Competence must be amended in the following circumstances: ❚ When a member of staff leaves (the Record of Competence must be stored securely in the pharmacy and a copy must be sent to the HR Shared Service Centre (HRSCC))

❚ When a new member of staff joins ❚ When a member of staff completes a training course that affects their level of responsibility within the pharmacy

❚ Additional copies are available on OnePortal

Dispensary Procedures: Standard Operating Procedure SI FM 101Date of preparation: August 2014


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14

Dispensary Procedures: Standard Operating Procedure SI FM 101 Date of preparation: August 2014


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10

Useful Pipcodes

Product Description Pipcode Ordering System and Warehouse Order

Branch Stamps – order form on Docs on Demand N/A Group Supplies 1

Controlled Drugs Register (complete) 828-1461 Merlin – Centurion 1

Controlled Drugs Blank Inserts 828-1479 Merlin – Centurion 1

Patient Returned CD register 830-5617 Merlin – Centurion 1

“Balance Checked and Verified” CD stamp 739-3499 Merlin – Centurion 1

A4 Methadone register (book) 818-7833 Merlin – Centurion 1

Controlled Drug Denaturing Kit 619-6034 Merlin – Langley 1

Pharmacist Stickers 601-8253 Merlin – Centurion 1

Fridge Stickers 601-8279 Merlin – Centurion 1

To Pay Stickers 602-1133 Merlin – Centurion 1

Caution stickers 828-0844 Merlin – Centurion 1

CD Stickers 668-7420 Merlin – Centurion 1

RP Certificate Holder 652-4797 Merlin – Centurion 1

Dear Prescriber Book 818-7809 Merlin – Centurion 1

Short dated stock stickers (Yellow & symbol) 829-1684 Merlin – Centurion 1

Small BasketsRed - waitingWhite - calling backBlue - problemSilver - PCS

601-8444601-8501601-8519601-8543

Merlin – Centurion 1

Medium BasketsRed - waitingWhite - calling backBlue - problemSilver - PCS

601-8550601-8626601-8584601-8618


Glass Measures10ml25ml50ml100ml

747-3424747-3366747-3309747-3242

1

Intervention and Referral Form 616-3935 Merlin – Centurion 1

Near Miss Log Book LloydsPharmacy point of Sale Materials 1

Owings Book 644-3592 Merlin – Langley 1

Unique Reference Number Stickers 611-8095 1

Specials Supply Log (previously Extemporaneous Prep)

826-1919 Merlin – Centurion 1

Clinical waste Container – small 612-2162 Merlin – Langley 1

Clinical waste Container – large 612-2170 Merlin – Langley 1


11

Useful Pipcodes

Product Description Pipcode Ordering System and Warehouse Order

Disposable non-latex gloves small medium large x - large

608-9338608-9312611-7485718-6315

Merlin - Centurion 1

Paper towels 612-1917 Merlin – Centurion 1

Apron 751-9499 Merlin – Centurion 1

Goggles 718-6513 Merlin – Centurion 1

Plastic disposable cups (60ml) 751-9788 Merlin – Centurion 1

Tweezers 602-3477 Merlin – Centurion 1

Anti-bacterial soap 612-1974 Merlin – Centurion 1

MUR folder 821-5295 Merlin – Centurion 1

MUR laminated barcode list 824-9700 Merlin – Centurion 1

Methadone leaflets 618-3123 Merlin – Centurion 1

Overdose leaflets 830-4651 Merlin – Centurion 1

Four way contract (Drug Users) 615-9024 Merlin – Centurion 1

Prescription signing board 704-4159 Merlin – Centurion 1

IPSS storage box 828-1784 Merlin – Centurion 1

Zero Tolerance of violence – A5 store sign/strut card 879-4224 Merlin – Centurion 1

Zero Tolerance of violence – A4 poster 879-4216 Merlin – Centurion 1

Secure filing cabinet 618-4352 Merlin – Centurion 1

A - Z index cards 601-6869 Merlin – Centurion 1

Support for People with Disabilities

Magnifying SheetsColoured StickersRecord of DDA requests padWinged non - child resistant closures

604-9985823-0864823-0476821-5220


My Med (complete) 826-2552 Stoke 250

NPA small container labels LAT100 (e.g. eye drops) 742-4476 Merlin – Centurion 20

Steroid cards 742-4476 Merlin – Centurion 25

Dispensary Procedures: Standard Operating Procedure SI FM 102Date of preparation: August 2014

12

SOP local variation template

To be completed by the Pharmacy Superintendents Office

Pharmacist Name: Pharmacist Name:

Registration Number: Registration Number:

Date: Date:

Signature: .......................................................................................................... Signature:

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To be completed by the Pharmacist requesting the change to the SOP

..................................................................................

Local Variation Reference (for office use): ................................................................................................................................................................................................................................................

Details of the current SOP to be amended: ...........................................................................................................................................................................................................................................

Explain in detail the proposed changes and the reasoning behind these changes.

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Pharmacy Details:

Pharmacist’s Name: Registration Number:

Date: Signature:

Fax to PSO for review: 0870 928 9766.