Issue May 2015
Change in Controlled Drugs Accountable Officer
Following the reorganisation within NHS England, the role of the Controlled Drugs Accountable Officer has now been transferred from Brigid Stacey to Sam Travis. Sam is now the Accountable Officer for NHS England North Midlands which covers Shropshire, Staffordshire, Derbyshire and Nottinghamshire.
All contact details for the Accountable Officer remain the same:
0113 825 4630
Healthcare professionals have a statutory duty to report all complaints, concerns or untoward incidents involving controlled drugs (Schedules 1- 5) to the Controlled Drugs Accountable Officer.
Examples of incidents that require reporting include (this list is not exhaustive):
-Prescribing errors involving CDs
-Patient complaints involving CDs
-Concerns with colleagues or patients
-Medicine Management CD issues
-Missing or lost CDs
-Discrepancies in the recording and stock levels of CDs
-Dispensing errors involving CDs
If you have a concern or make an error please report it; only by sharing this information can we learn from the incidents that have occurred. Your report may also help to inform wider concerns regarding controlled drugs.
Validity of Scripts prior to dispensing
Over the past quarter the CDAO has received a number of incidents relating to out of date prescriptions which have been dispensed against or post-dated scripts which have been dispensed against. We would like to remind all pharmacies that the validity of the prescription must be checked prior to dispensing to prevent these types of incidents occurring.
Timely Destruction of OOD Controlled Drugs
If you have OOD CDs awaiting destruction please ensure this is actioned in a timely manner. If you require an authorised witness to attend your pharmacy please contact Eleanor Carnegie 0113 8254 630 or via email at
Update on Schedule 2 & 3 Controlled Drugs and EPS
Legislation will come into force on 1 July 2015 to allow controlled drugs listed under schedules 2 and 3 to be prescribed and dispensed using EPS.
However, it should be noted that although this means using EPS for Schedule 2 & 3 controlled drugs will be legal, it will be some time later that it becomes technically possible as all EPS enabled dispensing system suppliers have to amend their systems before a GP system (which also need amending) can prescribe to a nominated dispenser. The HSCIC will be assuring supplier systems conform technically to legislative change requirements. .
Collecting prescriptions for CDs
From reviewing the recent controlled drug incidents reported there have been a series of incidents reported relating to prescriptions that are lost in transit. Prescription forms for Schedule 2 CDs should not routinely be sent to the patients’ pharmacy via the postal system but should be collected from the surgery. A SOP should be developed if CD prescriptions have to be regularly transported by mail / taxi etc. which reflects a risk management assessment. If it is necessary to send a CD prescription by mail, recorded delivery should be used.
Validity and duration of prescriptions
NHS and private prescriptions for Schedule 2, 3 and 4 CDs are valid for 28 DAYS from the appropriate date on the prescription.
The quantity of drug prescribed on each prescription should be appropriate for the clinical need of the patient. Careful consideration should be given to the quantities prescribed, both to anticipate requirements (e.g. over a weekend) and to reduce the amount of excess CDs stored in the patient‘s home.
Guidance has been given to make it clear that single prescriptions for CDs in schedules 2, 3 or 4 should normally be limited to a supply of 30 days. Only in exceptional circumstances where the prescriber believes that a supply of more than 30 days is clinically indicated and would not pose an unacceptable risk to patient safety, the prescriber should make a record of the reasons in the patient’s notes and should be ready to justify this decision if required.
Sharing Good Practice
As part of our review of all CD incidents that are reported to the controlled drugs accountable officer,we always look to see what lessons have been learned and if any changes to operational practice has taken place to minimise future incidents.
Key messages from quarter four January – March 2015 incidents :
-Undertake weekly/ fortnightly balance checks to identify balance discrepancies quickly and check stock levels are accurately recorded.
-Enter CDs in CD book before they are handed over, where possible - extra opportunity to check medication is correct.
-Keep the CD cabinet tidy so that strengths and formulations are more effectively separated
-Add a message onto a patient’s PMR as a reminder that to avoid errors occurring when there have been changes to strength or form.
-Take a sufficient mental break between preparing an item to be dispensed and checking the correct item has been selected before dispensing to patient, when a second individual is not available to assist in the process.
-Undertake a visual check of stock received against the delivery note.
-Always check the amount of stock in the split container before dispensing
-Include OOD CD stock in the balance checks
-Prepare care home medications in advance during quieter periods in the pharmacy, whenever possible
-Ensure empty boxes are double checked and broken down before being disposed of.