Medication Management Policy

Policy Code: POL 2

Date: 17/06/2014

Revised: 09/07/2018, 07/01/2021, 12/04/2025

Purpose:

• To ensure medication is stored in accordance with legislative requirements.
• To ensure a suitable supply of medication is maintained at the practice.
• To ensure medication is in-date and wastage is minimised.
• To reduce risk to staff and patients due to medication errors.
• To ensure patients' rights are protected.

Responsible Staff:

Implementation: Senior Practice Nurse

Action: All Clinical Staff

Audit: Senior Practice Nurse

Audit:

Training Resources:

Vaccine Ledger Folder situated on top of vaccine fridge.

Cold Chain Folder situated on top of vaccine fridge.

Ministry of Health Immunisation Hand Book 2017

Medication Stock list.  (Common Documents on Server Shared Drive S:/)

Medication location check list.  (Common Documents on Server Shared Drive S:/)

Anaphylaxis box contents check list.  (Common Documents on Server Shared Drive S:/)

Linked Policies:

Controlled Drug Prescribing Policy

Policy:

CONTROLLED DRUGS:

All controlled drugs are stored in the safe. This includes all benzodiazepines and tramadol.

Only controlled drugs which require a controlled drug prescription need be accounted for in the controlled drug book.

A comprehensive record of all controlled drugs should be kept in a bound volume with consecutively numbered pages and each page identifying one form of controlled drug.

The controlled drug book should be kept on top of the safe at all times and never taken off the premises.

All controlled drugs must be accounted for, two persons (one of whom should be a qualified Nurse or Doctor) should check and sign in and out of all controlled drugs.

Any out of date controlled drugs should be returned to the pharmacy and a signature obtained by a pharmacy staff member that they have taken the drugs for destruction.

In the event of a home visit or emergency when no other staff member is available the GP is responsible for documenting the entry at the next available business day following adminstration.

Any breakages/spillages should be accurately documented.

All entries must be legible, indelible and comply with current regulations.

Balances should be checked on a monthly basis.

Once the controlled drug book is full, this should be stored for a minimum of 7 years.

A policy statement which is suitable to be given to patients receiving controlled drugs is provided as the Controlled Drug Prescribing Policy.  This has been provided as a separate policy as it is specific to a small client group who may wish to access the information easily.  Prescribers should adhere to this policy as far as reasonably practicable as this ensures that clients are given consistent messages and prescriptions are produced safely.

Where possible, Controlled Drugs should be prescribed using NZePS.

When a Controlled Drug is prescribed using a triplicate pad, the prescription must be scanned into the PMS before it is handed to the patient.  This prevents dispute later as to what exactly was written.  If this is not possible for any reason, then the serial number of the prescription should be recorded in the notes along with a clear reason why the policy could not be followed.  Details of what was prescribed should be recorded. 

Where triplicate prescriptions are to be posted, they should be sent by recorded delivery courier.  This may be waived for prescriptions dated more than 7 days prior to posting as such cannot be used except at the pharmacy where the medication was dispensed.   NZePS CD scripts that have been sent to the pharmacy electronically may be posted in an ordinary envelope.  Those going to a patient must be sent by recorded delivery.

When new controlled drug pads are received, the senior practice nurse shall record the date of receipt and the serial number of the first prescription in the CD book.

VACCINES:

The duty nurse working each morning is responsible for monitoring the daily temperature of the fridge.

Check the minimum and maximum using the up and down arrows to the right side, top of fridge, document these temperatures on the log which is on the notice board on the wall next to the fridge. The temperatures should then be reset by simultaneously depressing the up and down arrows for 3 seconds and a beeping sound heard. The temperature should be checked between 8.30-9am each day.

At the beginning of each month, usually the 1^st unless this falls at a weekend the temperature log should be filed in the cold chain folder  and replaced with a new one ensuring it has the name of the surgery on and the month and year.

A weekly electronic report is automatically emailed to nurse via cloud based temperature monitoring.

Instructions for how to do this can be found in the cold chain folder.

The printout graph should be faxed or otherwise transmitted to Pegasus then filed in the folder.  An electronic copy of the graph should be stored in the Cold Chain folder on the Server Shared Drive (S:/)

Vaccines should be checked for expiry and rotated each month, at the same time as the temperature is checked.

Any abnormal (out of range temperatures, ie outside 2-8°) should be reported immediately to the immunisation co-ordinators at Pegasus Health. The Clinical Director must also be informed.

No food or laboratory specimens should be stored in the vaccine fridge. Food should be stored in the kitchen fridge, lab specimens should be stored in the lab specimen box.

Chilly bins and polystyrene boxes should be used for transporting vaccines for use off site. This may be necessary if defrosting the fridge or in the event of a power failure. When transporting vaccines, the temperature needs to be maintained between +2° to +8° at all times. A temperature monitoring device should be placed with the vaccines during this time.

Ice packs need to be frozen at least two days before being used for transporting vaccines. When placing ice packs in the freezer, set them on their edge and allow space between the ice packs, to ensure even freezing.

Key Points for Vaccine Transportation

• Use a solid wall chilly bin with a clip on lid.

• Use a chilly bin of a size suitable for the amount of vaccine to be transported.

• Use the appropriate number and sizes of ice packs for the chilly bin size to ensure the vaccines will remain at +2° to +8°C throughout their journey.

• Monitor the chilly bin with either a min/max thermometer or data logger.

• Before placing the ice packs in the chilly bin, warm them until frost no longer forms on their surface.

• Place shredded paper in the bottom of the chilly bin, then place the vaccines so that the most heat sensitive are nearest the ice packs and the most freeze sensitive are furthest away.

• Separate the ice packs from the vaccine by using shredded paper or a sheet of 10mm thick polystyrene foam. This will prevent contact with the ice packs and thus ensure they will not freeze the vaccines.

• Tape the chilly bin lid in place.

Following these recommendations will keep the temperature within +2° to+8°C for up to five hours and allows for the chilly bin to be opened briefly, up to four times.

It will take the chilly bin up to an hour to reach working temperature after preparation, so ample time needs to be allowed for this before transporting vaccines.

MEDICATION STORAGE

All medications and pharmaceuticals should be kept in a secure area, accessible only by clinical staff. Approved locations are:

Practice Safe.

Storage room.

The majority of medication and pharmaceuticals should be kept in the storage room out of reach of children.

Medications and pharmaceuticals should be stored in original packaging in the designated storage area and should never be left open, accessible or left on benches/trolleys.

Medications and pharmaceuticals should not be stored in low cupboards, open shelving or on desks.

Every month, the practice nursing team shall check the condition, expiry date and stock levels of all medication held at the practice.

Medication due to expire before the next audit shall be marked clearly to ensure that staff are aware that it is close dated. This will improve utilisation and reduce the risk of giving expired medication.

At least 2 weeks prior to expiry an MPSO should be completed and sent to the pharmacy to replenish stock keeping within the agreed stock levels.

Every 12 months, the Senior Practice Nurse shall discuss the stock of medications held with the Clinical Director.

Every 12 months, the Senior Practice Nurse shall check that the list of medication locations is current and appropriate.

Where staff intend to store medication in a novel location, this information should be communicated to the Senior Practice Nurse as soon as possible.

Change Log:

12/04/2025

Changed fridge monitoring to reflect current use of cloud based service.

07/01/2021

Added requirement to record CD pad numbers in CD book and methods of postage for CD scripts.

09/07/2018

Added reference to Controlled Drug Prescribing Policy

27/06/2018:

Added purpose of protecting patients' rights

Minor wording changes

17/06/2014:

Minor wording changes.

This policy replaces the following policies as of 10/05/2012:

Vaccine Storage Policy

Medication Storage Policy

Vaccine Rotation Policy

Medication Monitoring Policy

Controlled Drug Management Policy

Monitoring of Anaphylaxis Boxes Policy