Storage arrangements

Storage arrangements

Responsibilities

Each hospital’s medicines policy will set out the roles and responsibilities for the safe and secure storage of medicines on wards. For the most part, the appointed registered nurse in charge of the ward or clinical area (usually the ward manager or theatre manager) or other professionally qualified person (possibly an operating department practitioner or radiographer) must ensure that systems for the safe use and security of medicines are followed and that stocks are safeguarded. He or she may delegate some of the duties, such as access, to another nurse or to a member of the pharmacy staff, but the responsibility always remains with him or her. In almost all instances, medi-cines will be stored in locked cupboards or another secure receptacle, such as patients’ medicines cabinets, described above. The pharmaceutical service may assume responsibility for replenishment of these stocks, advise on the type and location of cupboards, regularly inspect and audit them and assure the quality of the product at the time of use. However, pharmacy staff are rarely in a position to do more than this as they do not administer or use the items stored. What is clear is that this arrangement does present some risks if the wrong patient’s medicines, stock items or medicines that are no longer needed are left in the patient’s locker and not managed appropriately.

Keys

The keys to medicines stock cupboards, drug trolleys and patients’ medicines cabinets should be labelled, kept separate and carried on the person of a nurse (or other qualified person in charge). Controlled drug (CD) cupboard keys should be kept on a separate ring that can be readily identified and carried by the assigned nurse in charge, that is, the senior registered nurse on duty for the ward or clinical area, identified as nurse in charge for that shift. This all has the effect of minimising unnecessary access to medicines. For self-administra-tion schemes patients may hold the key for their own medicines locker; the appointed nurse in charge as described above should keep a master key.

Cupboards and trolleys

Separate lockable cupboards should be available for internal and external medicines (constructed to the British Standard specification) and CDs. In small units, if space does not permit a separate cupboard for external medicines, they must be kept on a separate shelf, below those for internal use. A separate lockable medicine refrigerator must be available in all areas where medicines may require it, with a maximum minimum thermometer to enable regular checks that temperatures are maintained in the range 2–8 C. A num-ber of hospitals are now using automated systems to monitor the fridges used to store medicines: these fridges are linked to alarm systems in the event of fridge failure.

Medicines in current use on wards are either kept in a lockable trolley or in individual patient medicine cabinets or drawers, usually at the bedside; none of these must be used for permanent storage. The trolley must be immobilised when not in use, locked either in a cupboard or to a wall; it is not normally used for CDs. Patient medicine cabinets or drawers must be lockable and not readily portable. In some hospitals, patients’ medicines lockers are attached or an integrated part of their bedside locker, tend to be on wheels and are therefore portable to some extent. However, in practice this is seen as acceptable in many British hospitals.

Security

There are no published data to quantify the volume or cost of medicines that are misappropriated by hospital staff. Although the concept of diversion is rarely discussed, there are a number of anecdotal examples that suggest it is more common that most people would assume. Unpublished studies have suggested that as much as 20% of the medicines supplied to a ward will be unaccounted for.

Procedures and documentation need to minimise opportunities for misap-propriation and some departments ask nursing staff to sign for deliveries to ensure there is an audit trail from the point of ordering to the point of delivery to wards.

A minimum requirement to give an audit trail in a manual system is that the requisition has the signature of the ordering nurse, that pharmacy can verify, the issuer’s and checker’s signature is entered and a receipt is obtained. Serial numbering and book-fast copies (kept for a minimum of 2 years) minimise the opportunity for destruction of records to go undetected. Where requisition books are used there should be only one in each ward or department, kept locked away, with new ones treated as controlled station-ery, stocked only in pharmacy.

Exceptions

In some cases, organisations may decide that some medicines should be left in more readily accessible locations. Although this may not be ideal, a risk assessment may identify that this is an appropriate course of action.

Examples might include:

·      medicines in emergency kits or on emergency drug trolleys, in clearly labelled boxes with a tamper-evident seal, kept readily accessible

·      intravenous fluids, antiseptic and irrigation solutions

·      medicines considered appropriate for some patients to administer under the supervision of a registered nurse, unless there is a hazard to other patients.

The last situation is distinct from participation in a formally recognised self-administration scheme, which allows greater independence of action for patients and no limit on the range of medicines covered. There must be a valid prescription for the medicine. The prescriber may specify that the patient should have ready access to the preparation but generally this is not specifically required in medicines policies. The registered nurse may decide (and this should be documented) on whether to have the medicine on the patient’s bedside locker. The patient must be capable of administering the medicine correctly and willing and able to tell the nurse when a dose has been taken so that this can be recorded on the prescription sheet. Clearly, where a patient is using a medicine on a when-required or regular basis, a lack of awareness that the patient is doing so, that is, a lack of documen-tation on the drug administration record or prescription sheet, may mask a clinical issue that the team caring for the patient may wish to address. Examples include an increased use of glyceryl trinitrate spray, reliever inhalers or increased use of insulin devices. The medicine is likely to be in one of the following categories:

·      inhalers

·      glyceryl trinitrate sublingual tablets or spray

·      oral contraceptives and hormone replacement therapy products – ointments or creams

·      insulin preparations.