Controlled Audit of CD Accountable Trust Accountable Officer Accountable Drugs registers by Officer Board and Chief Pharmacist Officer pharmacy every 3 months. Annual audit of incident reports relating to CDs. Quarterly feedback of CD incidents by CDAO to CDLIN Annual audit of aspect of care by Accountable Officer Dispensing Continuous Dispensary Chief trends identified Dispensary errors/ near reporting via near manager Pharmacist and measures manager/ aseptic misses miss reporting and aseptic identified to reduce services manager forms and services risk of reoccurrence. via change in local dispensing error manager procedure and forms dissemination to staff Administration Continuous Chief Nurse MMC Any necessary Chief Nurse via errors reporting via NMAS change in procedure/ Associate Chief DATIX and drug need for additional Nurses. error pack. To be training identified. reviewed/ compiled quarterly. Safe storage Continuous Chief MMC Gaps identified by By wards or of medicines reporting via Pharmacist MMC and necessary pharmacy DATIX. To be actions fedback to reviewed/ Directorates/ compiled pharmacy quarterly Training To be reviewed at Chief MMC Gaps identified by Nursing/Pharmacy requirements annual appraisals Pharmacist MMC and necessary Management for pharmacy and actions fedback to nursing staff by Directorates/ line managers. pharmacy Safe disposal Audit of practice Wards MMC Gaps identified by Directorates of medicines Senior MMC and necessary Sister actions fedback to Pharmacy Directorates/pharmacy Operational Manager DATIX to be Chief MMC Gaps identified by Directorates reviewed Pharmacist MMC and necessary of medicines quarterly. Audit of actions fedback to missed doses Directorates
Controlled Drugs Audit of CD registers by pharmacy every 3 months. Annual audit of incident reports relating to CDs. Quarterly feedback of CD incidents by CDAO to CDLIN Annual audit of aspect of care by Accountable Officer Accountable Officer Trust Board Accountable Officer and Chief Pharmacist Accountable Officer Dispensing errors/ near misses Continuous reporting via near miss reporting forms and dispensing error forms Dispensary manager and aseptic services manager Chief Pharmacist trends identified and measures identified to reduce risk of reoccurrence. Dispensary manager/ aseptic services manager via change in local procedure and dissemination to staff Administration errors Continuous reporting via DATIX and drug error pack. To be reviewed/ compiled quarterly. Chief Nurse MMC NMAS Any necessary change in procedure/ need for additional training identified. Chief Nurse via Associate Chief Nurses. Safe storage of medicines Continuous reporting via DATIX. To be reviewed/ compiled quarterly Chief Pharmacist MMC Gaps identified by MMC and necessary actions fedback to Directorates/ pharmacy By wards or pharmacy Training requirements To be reviewed at annual appraisals for pharmacy and nursing staff by line managers. Chief Pharmacist MMC Gaps identified by MMC and necessary actions fedback to Directorates/ pharmacy Nursing/Pharmacy Management Safe disposal of medicines Audit of practice Wards Senior Sister Pharmacy Operational Manager MMC Gaps identified by MMC and necessary actions fedback to Directorates/pharmacy Directorates of medicines DATIX to be reviewed quarterly. Audit of missed doses Chief Pharmacist MMC Gaps identified by MMC and necessary actions fedback to Directorates Directorates
CORPORATE%20POLICY%20-%20Medicines%20Management%20Policy%20-%20POLCPCM033-6.docx