P25 Improving stock accountability of liquid controlled drugs using rulers in a children’s hospital

Context The Controlled Drugs (CD) (Supervision of Management and Use) Regulations 2013 lays out the legislation for monitoring management use CDs. 1 Inaccurate counting poor record keeping CDs can reduce staff time patient facing activities. 2 It is a national recommendation that visual inspections stock balance should happen in various points: periodic volume checks to confirm on completion bottle. 3 Due population, large proportion stocked Trust are liquid preparations designed multiple small administration. CD discrepancies contribute over 100 Datix incident reports annually. This largely due lost during manual manipulation bottle dosing weekly physical measurements undertaken by as per policy. estimated approximately one hour nursing ward/Theatre week were taken away from clinical care checks. also introduces contamination risk decanting, well generating plastic waste associated with checking. To mitigate risk, Trust’s Medicines Safety Committee (MSC) benchmarked against other paediatric centres. was found most did not undertake routine or measurements. Following Care Quality Commission’s National Group consider using calibrated aid inspection accurate , rulers increments explored. allow measurement be approximated without need decanting MSC’s approval, implementation introduced. Ward lists reviewed, manufacturers brands each preparation compiled into database. Training sessions (both virtual face-to-face) pharmacy delivered facilitated period three months, prior implementation. policy updated, local guidance developed, all eventualities covered. change practice communicated via email, nurse educators’ network, medicine safety newsletter. updated uploaded onto Pharmacy intranet webpage put up areas aid. Lessons Learned successful introduction have been received across Trust. required extensive support educational team. Feedback carried post suggestions used update guideline. Although there financial implications, has reduction number discrepancies-related incidents. They simplified sped prevent risks spillage, contamination, wastages. However, they cannot opaque bottles tailored specifically drug, strength, manufacturer, pack size, giving less flexibility response drug contract changes/shortages. A 6-month surveillance will conducted fully assess review this practice. References 2013. No. 373. Part 2. Regulation 12. Available at (legislation.gov.uk) [Accessed 10 June 2022]. (CQC’s) Group. Sub-Group Newsletter – April 2021. Issue 11. https://content.govdelivery.com/accounts/UKCQC/bulletins/2d6cbb6 05 August 2021]. Institute Health Excellence (NICE). drugs: safe (NG46). 2016.