Ward / Department Medicines Storage & Handling Audit Checklist

1. Measures are in place to ensure that medicines are received by an authorised staff member (registered healthcare professional) when they are delivered to the ward/department.

2. Delivered medication is always checked against the Delivery Note before it is locked away.

3. There is a process in place for dealing with any discrepancies between what is ordered and what is received. The process outlines what staff must do and who should be notified.<br><br>NOTE: This information is available in section 11.3 of the Medicines Management Handbook (available electronically on the intranet).

4. There is a list of authorised signatures for staff who can order medicines.<br><br>NOTE: Not applicable within SWFT. Currently non-stock medicines can only be ordered if they are accompanied by a prescription chart, at which point the prescriber is verified on the chart by the clinical checking pharmacist. Nursing staff signatures are not required.

a) INTERNAL MEDICINES - These should be clearly segregated from external medicines and locked away (with access restricted to authorised staff members only).

b) EXTERNAL MEDICINES - These should be clearly segregated from internal medicines and locked away (with access restricted to authorised staff members only).

c) FRIDGE & FREEZER MEDICINES - Fridges and freezers must be locked (with access restricted to authorised staff members only).

d) IV FLUIDS AND STERILE TOPICAL FLUIDS - These should be clearly segregated from oral medicines and locked away (with access restricted to authorised staff members only). <br><br>NOTE: Bulk fluids do not have to be locked away, however they should be out of the immediate view of the public.

e) FLAMMABLE LIQUIDS & MEDICAL GASES - These should be stored in a well ventilated area (particularly gases), away from sources of heat/ignition, where they cannot be easily knocked over.

f) TTOs/TTAs - These must be locked away (with access restricted to authorised staff members only).

g) EMERGENCY MEDICINES e.g. crash trolleys/anaphylaxis kits - These must be secured with a tamper-evident seal and stored out of the immediate view of the public (they do not have to be locked away).

h) MEDICINES TROLLEY(S) - These must be locked and secured to the wall or immobilised when not in use.

i) PATIENT MEDICATION (POD) LOCKERS - These should be locked into position and no medicines should be left unattended outside of them.

j) EPIDURALS

k) DIAGNOSTIC REAGENTS (e.g. urine test sticks) - These should be kept separate from other medication.

6. All cupboards, closed storage units and fridges containing medicines are lockable.<br><br>NOTE: Physically check that they are locked if they are not in use (unattended).

7. There is adequate secure storage space for all medicines on the ward/department.<br><br>NOTE: Check all areas for any instances where medicines could not be locked away due to lack of space e.g. the tops of cabinets.

8. All medicine containers are in good repair with a visible expiry date and batch number (where applicable). There are no loose strips of tablets in medicines cupboards/trolleys.<br><br>NOTE: Check ALL cupboards, trolleys and fridges containing medicines.

9. Pharmacy stock requisition forms and blank prescription forms are stored in a locked cupboard or drawer with restricted access.

10. Requests for medicines are made either electronically or on stationery which is approved by the Trust.

11. The min, max and current temperatures of the medicines fridge(s) are recorded daily and the thermometer reset after each recording. There is documented evidence available to show that action is taken when the temperature falls out of range either regularly or by more than a few degrees.<br><br>NOTE: Fridge temperatures should remain within 2-8 degrees Celsius.

12. The min, max and current temperature of the main room where medicines are stored is recorded daily and the thermometer reset after each recording. There is documented evidence available to show that action is taken when the temperature falls out of range either regularly or by more than a few degrees.<br><br>NOTE 1: Not applicable for areas where Estates' Buildings Maintenance System constantly monitors the temperature. <br>NOTE 2: The 'room temperature' should generally be between 15-25 degrees Celsius, however if temperatures exceed 26 degrees Celsius (e.g. during a heatwave) evidence should exist that Pharmacy was notified or advice from Pharmacy was taken.

13. Evidence exists that temperature monitoring devices are calibrated (or replaced) annually.

14. The ward/department has a copy of their agreed stock list, which has been reviewed no less than annually by the Ward Manager, nurse in charge or Ward Pharmacist.

15. The keys providing access to medicines are in the possession of an authorised person (e.g. registered nurse) or are securely stored with access restricted to authorised staff only. They must be easy to locate at all times.

16. The medicines trolley(s) are locked and immobilised (i.e. chained to the wall or locked in a room with restricted access) when not in use.

17. Doors leading to security sensitive areas (where medicines are stored) are access-controlled.

18. Where PIN codes are used as part of the access-control system, the code is changed regularly (at least when staff who know the code leave the Trust, or following a breach in security).

19. Clinical information about medicines and their use(s) is available on the ward/department e.g. a hard copy of the BNF (dated within the last 12 months) or staff have access to the online BNF.<br><br>NOTE: All hard copies of the BNF that are older than 12 months must be removed from clinical areas.

20. The most up-to-date version of the NMC Standards for Medicines Management is available to nursing staff in the ward/department.

21. The Trust Medicines Policy and Medicines Management Handbook (containing procedural detail) is available to staff on the ward/department.<br><br>NOTE: There may be hard-copies or staff should know how to access the electronic versions on the Medicines Management intranet site.

22. There are no unattended medicines on the ward/department e.g. syringes that have been prepared for administration and put to one side.<br><br>NOTE: Check ALL accessible areas of the ward/department.

23. Medicines that are no longer required are stored securely before they can be returned to pharmacy. Expired medicines and PODs that the patient has consented to have destroyed are disposed of in the blue pharmaceutical waste bin on the ward/department.<br><br>NOTE 1: Check that the red pharmacy drug box/bag(s) are locked/secured if they contain medicines. <br>NOTE 2: Check that the blue pharmaceutical waste bin is present and appears to have been used correctly (i.e. boxes/medicine containers should be disposed of in the GENERAL waste unless they have been in physical contact with medication).

24. Medicines that are stored in AUTOMATED storage cabinets are secure (access is restricted to authorised staff members only).

ROLE