1. Medicines Management in the Care Home Setting Your Care Home 29 th At a date to suit 2012 Rob Hebdon Bsc (Hons) MGPhC

2. Introduction Rob Hebdon BSc (Hons), M.R.Pharm.S. Community Pharmacist – Senior Nursing Home Support Primary Care Trust (PCT) – Practice based pharmacist

3. Introduction Medicines management in the care home Good practice and record keeping Comply with the requirements of the drug audit trail

4. Guide to the Drug Audit Trail what is the drug audit trail? areas of responsibility taking receipt of the monthly repeat order drug administration procedures prescription re-ordering general points and guidelines

5. What is the Drug Audit Trail? The Nursing Homes and Mental Nursing Homes Act Regulations 1984 –12(1)(0) require: the person or persons registered to make adequate arrangements for the recording, safekeeping, handling, administration and disposal of drugs.

6. What is the Drug Audit Trail? in other words…… It is the responsibility of the Care Home / Person in charge to have a system(s) in place and in use, which allows the Home (and other auditing and/or inspectorate bodies) to account for the movement of every single medicinal dose within that home, from the moment of receipt upto and including its administration, destruction or return.

7. What is the Drug Audit Trail? in other words…… Accountability through good practice and good record keeping

8. Monitored Dosage System (MDS)

9. Areas of Responsibility Diagnosis and Prescribing-G.P. Prescription collection-Care Home Prescription checking- Care Home Prescription declaration-Care Home Prescription to Pharmacy-Care Home Safe Dispensing / Audit-Pharmacist Delivery and notification of owings-Pharmacy Checking in-Care Home Identification and Notification of errors / changes-Care Home Administration-Care Home Safe keeping-Care Home Disposal-Care Home Re-ordering and obtaining prescriptions-Care Home Reference: - NMC guidelines to good practice - Health Authority Nursing Home inspectorate

10. Taking Receipt of Medication

11. Taking Receipt of Monthly Repeats 1. Check all medication details on new MAR sheets against those MAR sheets in current use. List all queries or discrepancies with new MAR sheets and discuss with your CHEMIST or GP as appropriate.

12. Taking Receipt of Monthly Repeats 2. Complete “received” box with the amount received and the date. Confirming the “quantity” as that received.

13. Taking Receipt of Monthly Repeats

14. 2. Complete “received” box with the amount received and the date. Confirming the “quantity” as that received.

15. Taking Receipt of Monthly Repeats 3. Nurse’s initials to be added to “by” box (or equivalent).

16. Taking Receipt of Monthly Repeats

17. 4. List all queries or discrepancies with new MAR sheets and discuss with your CHEMIST or GP as appropriate.

18. Drug Administration Procedures

19. DRUG ADMINISTRATION PROCEDURES [Supplementary to home drug administration policy] The law requires that medicines are given to… the right person at the right time in the correct form at the correct dose via the correct route

20. DRUG ADMINISTRATION PROCEDURES [Supplementary to home drug administration policy] Check the identity of the resident. Check the MAR sheet to confirm that medication is actually due. [The numbers at the top of the columns on each white sheet represent the number of days treatment remaining in the 28- day repeat cycle, NOT THE CALENDER DATE. Drug administration, which starts at the beginning of the cycle, is recorded under the ‘28’ column, and this corresponds with the ‘28’ on the CHEMIST blister pack, also clearly marked ‘START’. The actual calendar start-date of the cycle is specified at the top of the MAR sheet.] Having checked the dose is due, check in the appropriate box on the MAR sheet that the dose has not already been administered.

21. DRUG ADMINISTRATION PROCEDURES Locate the blister pack, and check that the instructions on the label exactly match the instructions on the MAR sheet. Locate the blister bubble that corresponds to the current day. Check the identification of the resident again before pushing out the bubble contents into a suitable container e.g. medicine pot, push from the front through the foil and out of the back. Give the dose to the resident. When the medication has been taken i.e. witnessed, initial the correct box on the MAR sheet.

22. DRUG ADMINISTRATION PROCEDURES Any doses removed from the blister, but not taken by the patient, can be placed in a separate and specially marked container for return to your CHEMIST and should not be flushed into the drains. This container should be returned when full. Ensure that the MAR sheet is annotated appropriately with one of the codes at the bottom of the MAR sheet.

23. DRUG ADMINISTRATION PROCEDURES If for whatever reason the medication is not removed from the blister, e.g. resident in hospital, clearly circle that particular bubble on the front of the pack, and document the reason for non-administration on the MAR sheet using the appropriate code from the bottom of the MAR sheet. This dose should be left in the blister pack and then next one used at the next administration time.

24. Re-ordering Procedure

25. RE-ORDERING Timing is important. Please ensure that requests for prescriptions are ready to be sent to the surgeries by the fourteenth day of the cycle at the latest. The following schedule, or a similar version, should be typical; 14 - 16 days from start date – Prescription requests sent to surgeries 10 days from start date – Prescriptions returned to home by surgeries and checked by residential / nursing home staff 9 days from start date – Prescriptions sent to your CHEMIST 2 - 3 days from start date – All medication and MAR sheets delivered

26. RE-ORDERING If using pink and yellow copies of the MAR sheets! They are self-carbonating, keep them together when making out the requests on the pink copies. Request 28 days of each repeat medication required by writing ‘28’ in the column headed ‘no. of days treatment’. If 28 days’ of treatment does not equate to a definite quantity, state the quantity required. E.g. Paracetamol tablets, 2 PRN, 100 tablets required.

27. RE-ORDERING Once the prescriptions have returned from the surgery, which usually takes 2-4 days, they should be checked against the yellow copy of the MAR sheet to ensure that you have been prescribed what you ordered.

28. RE-ORDERING Surgeries that have not sent prescriptions back to you within 5 days should be followed up. Your CHEMIST may collect prescriptions from the home once they have been checked, or may occasionally ask for them to be forwarded by first-class post. Please ensure that either the pink / yellow copy of the MAR sheet request, or a photocopy of the of the prescription request slip, is sent with each prescription in order that the computer records can be updated at the pharmacy. This is extremely important as the following month’s MAR sheet information may not be correct, as the pharmacy will not have received all the relevant information to amend the sheets accordingly. I.e. items that have been discontinued, directions altered etc.

29. Acute Treatments and Alterations

30. ACUTE TREATMENTS AND ALTERATIONS Prescriptions should be obtained for all for short courses, additional items or changes to regular monthly medication. Where possible the following procedure should be followed to minimise errors. Fax the prescriptions to your CHEMIST (or your delegated local pharmacy). Pharmacy will contact you if the fax is incomplete or if there is a query. Request the GP to make, or endorse, the written instructions on the MAR sheet, to acknowledge their accuracy. Alternatively attach the spare label supplied by the pharmacy with the prescription to the next available blank line on the MAR sheet.

31. ACUTE TREATMENTS AND ALTERATIONS Alterations to existing treatments should be recorded on a new line on the MAR sheet, and not made in hand to the printed instructions already on the sheet. The existing item on the MAR sheet should be annotated as changed and referred to the new item. Report all alterations in treatment to your CHEMIST so that computer records can be kept up to date.

32. Disposal

33. Disposal of Medicines Use your Pharmacy – Don’t flush down sink / toilet Returns Policy – Returns book – Use MAR sheets

34. General Guidance

35. General Guidelines 100% compliance with all necessary paperwork – Appliance / environment maintenance – Care Notes – CD register – MAR charts - the first thing I will inspect If you havent recorded it – you havent done it

36. General Guidelines Paperwork is there to protect you! – It provides evidence of the good job that you do! If you haven’t recorded it – you have not done it

37. General Guidelines CORRELATION BETWEEN BLISTER PACKS AND MAR SHEETS. – The reverse numbering system on the back of the blister pack correlates with the numbering on the MAR sheets. THESE DO NOT CORRESPOND WITH THE CALENDAR DATE.

38. General Guidelines SHELF LIFE – Medication supplied in blister packs should not be administered 8 weeks after the date on the label. Any such packs should be returned your CHEMIST for destruction.

39. General Guidelines ITEMEXPIRY Tablets or Capsules6 months Liquids3 months Insulin28 days when opened Creams / Oint in tubes3 months when opened Cream / Oint in pots28 days when opened Eye drops / oint28 days once opened SpecialRefer to Pharmacy!

40. General Guidelines REMEMBER – IF THERE ARE EVER DOUBTS OR CONCERNS RELATING TO ANY ASPECT OF MEDICATION, OR MEDICINE MANAGEMENT, PLEASE CONTACT YOUR CHEMIST IMMEDIATELY