NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST MEDICINES CODE OF PRACTICE MEDICINES IN THE OPERATING THEATRE Reference Date approved

Approving Body Implementation date Version Supersedes Consultation undertaken Target audience Supporting Procedure(s) CL/MM/014 21 August 2009 Directors Group 21 August 2009 2 Version 1 (March 2008) Theatres staff, Chief Perfusionist, Medicines Management Committee All NUH staff who deal with medicines in Theatres NUH Drugs Administration Policy for Clinical Perfusion Scientists Guide to Good Practice in Clinical Perfusion (Dept of Health 2009) July 2012 Medical Director, NUH MMC, NUH

Review Date Lead Executive Author/Lead Manager

Further Guidance/Information Pharmacy Medicines Information 14.1 INTRODUCTION Practices involved in the prescribing and administration of medicines in operating theatres differ substantially from those followed on hospital wards. The contents of other sections of this Medicines Code of Practice still apply in theatres, subject to the special provisions detailed below. The term doctor is applied to any medically trained professional who may administer medicines in theatre. In practice this is usually an anaesthetist, but the term also encompasses surgeons and other doctors using the theatre facilities.
Medicines in the Operating Theatre Version 2 August 2009 Page 1 of 10

The Head of Service for Theatres, in collaboration with the Chief Pharmacist, is ultimately accountable for ensuring secure systems for the ordering, custody and availability of medicines (including Controlled Drugs). The implementation of these systems may be delegated on a day-to-day basis to appropriately registered theatre practitioners by the theatre team-leaders or theatre co-ordinators. 14.2 SPECIALIST PROFESSIONAL GROUPS 14.2.1 Operating department practitioners (ODPs) A registered ODP must be registered with the Health Professions Council. ODPs will be included under the term theatre practitioner throughout this procedure. A registered ODP may be given the same responsibilities to a registered nurse regarding the management of medicines in theatre. A registered ODP who has received the appropriate training and assessment may undertake an expanded role in drug administration. 14.2.2 Clinical perfusion scientists Clinical perfusion scientists (perfusionists) are specialist autonomous practitioners involved in the management of patients undergoing cardiac surgical procedures. Qualified perfusionists employed by NUH must be registered with the College of Clinical Perfusion Scientists of Great Britain and Ireland. Qualified perfusionists do not administer medicines within the provisions of the Medicines Act 1968, nor do they do so under patient group directives (PGDs). The perfusionists at NUH work under delegated authority from the Clinical Director/ Trust following detailed guidance and working to competencies as outlined in the NUH Drugs Administration Policy for Clinical Perfusion Scientists. This policy stipulates the range of medicines, which may be administered, and in what circumstances.

Medicines in the Operating Theatre Version 2 August 2009 Page 2 of 10

The current version of the NUH Drugs Administration Policy for Clinical Perfusion Scientists is available on the Medicines Management Committee website. 14.3 PRESCRIBING AND ADMINISTRATION OF MEDICINES RESPONSIBILITIES OF THEATRE STAFF Theatre staff have varying responsibilities for the management of medicines in theatre (including controlled drugs) according to their professional registration and grade. The Head of Service for Theatres must ensure that each member of staff is aware of their responsibilities as part of the job induction process. (See local procedures). Sections CLMM006 (Prescribing) and CLMM008 (Administration) of this Medicines Code of Practice must be followed wherever possible. It is recognised that it is impractical for anaesthetists to have a second check for each individual administration of medicines (by whatever route) during the course of an anaesthetic. However it is good practice to ask for a second check when the medicine is to be administered to a paediatric patient, where there is a critical dilution or the anaesthetist is unfamiliar with the medicine to be administered including (but not limited to) cytotoxic drugs, inotropes and anticoagulants. The anaesthetist who is responsible for the conduct of an anaesthetic, is responsible for the preparation and administration of all medicines that they administer (by any route) during the course of that anaesthetic. The anaesthetist is also responsible for the preparation and administration of medicines by a supernumerary anaesthetist, theatre practitioner or medical student within their sight and under their direct supervision. The anaesthetist is responsible for recording all medicines given during the course of an anaesthetic. Generally this record will be the NUH anaesthetic chart, although medicines may also be signed for on the NUH inpatient prescription chart.

Medicines in the Operating Theatre Version 2 August 2009 Page 3 of 10

If the medicine is to be continued into the post-operative period, it must be prescribed on the inpatient prescription chart. Administration of any medicines that have been given in theatre which affect the subsequent dose of the same (or another) medicine must be documented on the inpatient prescription chart. A surgeon, or any other doctor using the operating theatre facilities, is responsible for the ensuring the appropriateness of any medicine and its dose given by themself or at their request. They may delegate administration to a theatre practitioner by means of a written or verbal instruction. Any theatre practitioner administering a medicine under this type of direction is responsible for ensuring that the medicine is administered in the correct manner. Where a verbal instruction is given, the theatre practitioner must repeat the verbal order back to the doctor to confirm the correct medicine and dose. The usual rules for second checking apply (see section CLMM008). Confirmation in writing must be made as soon as possible by the surgeon either on the operation record or on the NUH inpatient prescription chart and signed by the practitioner who administered the medicine. The responsibility for the appropriateness and dose of medicines to be given in theatre lies with the prescriber. This includes medicines prescribed on the inpatient prescription chart for intra-operative administration by the anaesthetist. The person who administers the medicine prescribed in this way (including doctors or theatre practitioners) is responsible for ensuring that the medicine is administered in the correct manner.

Medicines in the Operating Theatre Version 2 August 2009 Page 4 of 10

14.4 ISSUE AND SUPPLY OF MEDICINES (OTHER THAN CONTROLLED DRUGS) IN THEATRES 14.4.1 Ordering In all theatre areas, pharmacy staff provide a regular top-up service for all stock medicines against agreed stock levels. Further emergency supplies can be obtained from pharmacy using an Emergency Stock Requisition signed by an authorised theatre practitioner (Section CLMM003 of this Medicines Code of Practice (Supply of Medicines from the Pharmacy Department)). 14.4.2 Transport and receipt Orders will be sent to theatres in sealed containers. These medicines must be put away securely in a timely fashion to prevent any unauthorised access to them. (Refer to local procedures). 14.4.3 Managing discrepancies Refer to Section CLMM021 (Stock discrepancies) of this Medicines Code of Practice. 14.4.4 Security of medicines when a theatre is not in use When a theatre is not in use, all medicines must be put away in a locked cupboard or fridge. Medicines must not be left in or on the anaesthetic machine. Part-used ampoules and medicines no longer required must be disposed of correctly. Medicines (with the exception of controlled drugs) must be accessible at all times in the emergency theatre, unless there are no patients booked for theatre, or there is a planned break in operating. At these times the medicines must be put away in a locked cupboard or fridge as appropriate. In maternity theatre, an agreed stock of emergency medicines must be left accessible for the anaesthetist to prepare for emergency procedures before the theatre staff arrive.

Medicines in the Operating Theatre Version 2 August 2009 Page 5 of 10

14.4.5 Administration of single patient use ampoules or vials Ampoules or vials of medicines that are intended for single patient use must not be administered to any other patient. This includes the use of bags of intravenous fluids for dilution of medicines. Refer to Section CLMM028 of this Medicines Code of Practice (Use of Single and Multiple Use Vials) 14.4.6 Disposal of unused medicines Any medicines that are opened but not required must be disposed of according to Trust policy (see Section CLMM011 (Return and Disposal of Non-controlled Medicines) of this Medicines Code of Practice). It is the responsibility of the doctor or theatre/recovery practitioner administering the medicines to ensure that waste medicines, ampoules, needles and syringes are disposed of properly. 14.5 MANAGEMENT OF CONTROLLED DRUGS IN THEATRE Also refer to section CLMM012 of this Medicines Code of Practice (Controlled Drugs) 14.5.1 Ordering Orders for controlled drugs will be made in the Controlled Drug order book following local procedures. (Refer to local procedures). 14.5.2 Transport and receipt A messenger from theatres, who must be aware of the extra responsibility of handling controlled drugs, will collect the controlled drugs from pharmacy. Controlled drugs will be sent to theatres in a numbered sealed bag, which must be signed for on arrival in theatres (Refer to local procedures.) 14.5.3 Instances where the controlled drug keyholder is unavailable Procedures must be in place to deal with the receipt of controlled drugs when theatre staff are unavailable to take receipt of the sealed bag from the messenger. (Refer to local procedures.) 14.5.4 Controlled drug register

Medicines in the Operating Theatre Version 2 August 2009 Page 6 of 10

A dedicated theatre controlled drugs register must be used for recording all controlled drug transactions in theatres. The register must be kept within the locked controlled drug cupboard when the theatre is not in use. There are procedures in place for completing the controlled drug registers (Refer to local procedures). 14.5.5 Issuing controlled drugs Theatre practitioners must only issue the required number of ampoules for the current patient to the anaesthetist. These controlled drugs must be handed to the anaesthetist and signed for at the time of issue. 14.5.6 Stock control Stock balances for each controlled drug cupboard must be checked on a regular basis as decided by the Theatre Service Lead and follow local procedures. 14.5.7 Borrowing of controlled drugs The transfer of stocks (unopened boxes) of controlled drugs between theatres is not permitted. A single dose may be given to a named patient in one theatre from stock in another, with all the necessary entries being made in the Controlled Drug register of the issuing theatre. 14.5.8 Disposal of unused controlled drugs The anaesthetist must return any unopened ampoules of controlled drugs to the theatre practitioner who is holding the theatre keys. Both the anaesthetist and the key-holder must ensure that the returned ampoule(s) are returned to the controlled drug cupboard and this is recorded in the Controlled Drugs register. (Refer to local procedure). Any controlled drugs which are opened but not required must be disposed of according to Trust policy (Refer to section CLMM012 of this Medicines Code of Practice). The waste of controlled drugs should be witnessed by another theatre practitioner, and the wasted drug must be recorded in the controlled drugs register. It is the responsibility of the doctor or theatre/recovery practitioner administering the medicines to ensure that waste medicines,
Medicines in the Operating Theatre Version 2 August 2009 Page 7 of 10

ampoules, needles and syringes are disposed of appropriately. (Refer to section CLMM011 of the Medicines Code of Practice) 14.5.9 Managing discrepancies Any discrepancies between the controlled drug register and the stock levels must be investigated immediately. (Section CLMM012 (Controlled drugs) of this Medicines Code of Practice). 14.6 LOCAL ANAESTHETICS AND EPIDURAL INFUSIONS Refer to section CLMM029 of this Medicines Code of Practice (Local anaesthetics including epidural administration) Bags containing local anaesthetics intended for epidural infusion must be kept in a designated storage area in the theatre suite. If the infusion bag also contains controlled drugs, the bags must be stored separately from controlled drugs that are to be administered by any other route. All epidural infusion bags and syringes must be labelled with the yellow For Epidural Use Only stickers. If the bag or syringe does not already carry this sticker, it must be applied by the member of staff preparing the infusion. 14.7 TRANSFER OF PATIENTS WITH INFUSIONS FROM THE THEATRE SUITE If a patient is transferred from theatres to another clinical area with any medicine(s) by infusion (including infusions of controlled drugs), the syringe / infusion must be clearly labelled with the name of the medicine(s) and dose(s) thereof. (Section CLMM008 (Administration of Medicines) of this Medicines Code of Practice). The volume of any infusion containing a controlled drug must be checked and documented before leaving recovery and on arrival on the receiving ward by two practitioners at each stage.

Medicines in the Operating Theatre Version 2 August 2009 Page 8 of 10

14.8 KEY SECURITY Each operating theatre has its own set of keys. Some of these will provide access to medicines and controlled drugs. There must be a record kept of the function of all the keys for a particular theatre set, which must be kept up to date. The set of keys must not be divided unless the Matron for Theatres for that campus has given authorisation for a key, or keys, to be removed. (Section CLMM022 (Safekeeping of Keys) of this Medicines Code of Practice). The Matron for Theatres for that campus must ensure that every theatre practitioner who is an authorised key holder has submitted a sample signature. The Matron for Theatres must ensure that this list is current, and that practitioners who no longer work in NUH Theatres have this authorisation removed from the list. Theatre practitioners must follow the procedure for the allocation of theatre keys at the beginning of the theatre session, and the procedure for the return of theatre keys when the session finishes. During a session, the theatre keys may be held by other authorised theatre practitioners but all handovers must be documented to establish an audit trail. (See local procedures).

Medicines in the Operating Theatre Version 2 August 2009 Page 9 of 10

EMPLOYEE RECORD OF HAVING READ THE POLICY Title of Policy/Procedure: MEDICINES CODE OF PRACTICE MEDICINES IN THE OPERATING THEATRE I have read and understand the principles contained in the named policy.

PRINT FULL NAME

SIGNATURE

DATE

Medicines in the Operating Theatre Version 2 August 2009 Page 10 of 10