SOP 4 Template Standard Operating Procedure For Transfer of Stock Controlled Drugs To or From T
SOP 4 Template Standard Operating Procedure For Transfer of Stock Controlled Drugs To or From T
SOP 4 Template Standard Operating Procedure For Transfer of Stock Controlled Drugs To or From T
Objectives
Ensure that controlled drug (CD) stock held in GP bags is in date and the stock holding level
reflects demand and is appropriate.
Ensure the transfer of stock CDs to/from the doctor’s bag is managed safely and
securely.
Ensure that the documentation is accurate and reflects the current stock position in both
the doctor’s bag and the Practice’s stock.
Scope
This SOP encompasses the process and record keeping of transferring controlled drugs to/from
the doctor’s bag.
Responsibilities
Security of his/her bag in their possession, ensuring it is locked and they retain the
key. Note: a digital combination lock on the bag may be more practical and convenient.
Completing the appropriate CD registers following the transfer of CDs to/from the
doctor’s bag.
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NHS Blackburn with Darwen CCG
NHS East Lancashire CCG
If a GP wishes to carry controlled drugs in his/her bag, the following should take place:
1. An authorised staff member should witness both the GP stocking the bag from the
Practice CD stock and the appropriate entry being made into the Practice’s CD register
of the drug supplied including:
a. Date supplied
b. Name of drug, form and strength
c. Quantity
d. Running balance of stock updated.
2. The CDs should be stored in a locked bag, which can only be opened by the person in
lawful possession of the bag i.e. the doctor/prescriber.
3. Bags containing CDs should not be left in a vehicle overnight or for long periods of time.
4. Each doctor is responsible for the receipt and supply of CDs from their own bag and must
keep a CD register for the controlled drugs carried in their bag. There must be a separate
register for each doctor’s bag.
5. When CD stock is transferred from Practice stock to the doctor’s bag an entry must be
made in the bag’s CD register on the appropriate page for the drug received including:
a. Date received
b. Name of drug, form and strength
c. Quantity
d. Running balance of stock updated.
7. If a CD in the bag has expired, to avoid misuse, the doctor should return the CD to the
practice stock to await future destruction. A record of this transaction should be recorded
in both the bag and the Practice CD registers. If there is no Practice stock then the
expired CD would need to be destroyed directly from the bag and witnessed by an
authorised person. A record should be made.
8. The doctor with a delegated member of staff should undertake monthly stock checks of
CDs held within each bag for home visits and a record, signed and dated, made in the
register to indicate the stock check has been done.
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NHS Blackburn with Darwen CCG
NHS East Lancashire CCG
9. The expiry date on each product should be checked. Any product which is out of date
should be clearly marked as “out of date” and segregated from other stock for future
destruction. Refer to the SOP for disposal of CDs.
10. The stock levels of controlled drugs should be assessed and more stock ordered if
required. Refer to the SOP 7 for requisition of controlled drugs.
11. Any discrepancy between the stock and the register must be investigated. If the issue
cannot be resolved the NHS England CD Accountable Officer must be informed.
References
1. The Misuse of Drugs (Safe Custody) Regulations 1973 (SI 1973 No. 798)
http://www.legislation.gov.uk/uksi/1973/798/made?view=plain
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