Dispensary Standard Operating Procedures Toolkit

This document is a draft - before using any part of this material, Practices should check the contents and adapt the text to suit their circumstances and style.

DISPENSARY STANDARD OPERATING PROCEDURES TOOLKIT

INTRODUCTION As part of the changes to the arrangements for dispensing doctors for April 2006, agreed as part of the GMS changes in 2006/07, the Dispensary Services Quality Scheme ('the Scheme') came into effect on 26th September 2006. The Scheme rewards Practices financially for providing high quality services to their dispensing patients.

Practices which sign up to the Scheme must meet key quality requirements, one of which is to develop and maintain a set of Standard Operating Procedures ('SOPs') which reflect good professional practice and cover all dispensary procedures. SOPs must be reviewed and updated at least once every 12 months and whenever dispensing procedures are amended.

This toolkit gives Practices a starting point for the development of its SOPs. There are variations in the way Practices run their Dispensaries - the examples below give

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 1 of 17 broad guidelines and will need to be adjusted to reflect the way your Dispensary operates.

CONTENT OF A TYPICAL SOP

Content of each SOP will be specific to the needs of the individual Dispensary, and will depend on local needs and staff competencies. In overview, a typical SOP will include:

 Purpose – what the SOP is for  Scope – what the SOP covers  Process or procedure – detailed steps which are to be taken  Responsibilities – who is responsible for what, including delegation and back-up arrangements  Review arrangements – how often, or under what circumstances, the SOP is to be reviewed  Risks – details of things that could go wrong, how to minimise such risks, and the procedure for recording significant events  Acceptance – signatures of relevant staff

A typical set of SOPs is likely to comprise the following:

 Receiving prescriptions  Pharmaceutical assessment – validity, safety and clinical appropriateness  Interventions and problem solving  Assembly and labelling  Accuracy checking  Transfer to the patient

On the following pages are some draft suggestions for the contents of the typical SOPs noted above. These suggestions are intended purely as a basis for thought and discussion; First Practice Management can accept no responsibility for the way in which these drafts may be used by Practices.

In addition, a blank template sheet for developing further SOPs is at Appendix A.

Other relevant documents:

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 3 of 17  Significant Events toolkit [*]  Confidentiality Policy (Dispensers) [*]  Dispensary Risk Management Policy [*]  Dispensary Staff Training/Competency Records [*]

SOP: RECEIVING PRESCRIPTIONS. Version no. and date Purpose: what the SOP is for, e.g.: To set out procedures for the accurate and timely handing of prescriptions Scope: what the SOP covers, e.g.: The handling of acute and repeat NHS and private prescriptions Process/procedure: detailed steps which are to be taken, e.g.: Greeting patient and checking identity Check that Parts 1, 2 and 3 on the reverse of the prescription have been completed appropriately/correctly Checking that prescribed items are in stock (and refer to the process for ordering out of stock items) Advise patient of anticipated waiting time Put prescription in the queue for dispensing Responsibilities: who is responsible for what, including delegation and back-up arrangements (e.g. in case of holidays/sickness etc.), e.g.: All Dispensary staff also note arrangements for sickness/holiday

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 4 of 17 cover Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.: The SOP will be reviewed annually, next review due: It will also be reviewed in the event of any of the following:  Changes in relevant legislation or recommended guidance  Changes in staffing  Following an error or significant event Risks: details of things that could go wrong, how to minimise such risks, and the procedure for recording significant events, e.g.: Patient identification errors (e.g. popular names like Smith) Acceptance: Signatures (dated) of relevant staff:

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 5 of 17 SOP: PHARMACEUTICAL ASSESSMENT - VALIDITY/SAFETY/CLINICAL APPROPRIATENESS. Version no. and date Purpose: what the SOP is for, e.g.:

To ensure that all prescriptions dispensed are safe, clinically appropriate, legally valid, and cost-effective Scope: what the SOP covers, e.g.: All acute and repeat NHS and private prescriptions Process/procedure: detailed steps which are to be taken, e.g.: Check the prescription has been signed/dated and is an original* Check for compliance with the Practice formulary* Check appropriateness of dosage/form/patient’s condition/duplication of other medication/drug interactions/side effects** Responsibilities: who is responsible for what, including delegation and back-up arrangements (e.g. in case of holidays/sickness etc.), e.g.: Items marked * Dispenser Items marked ** Prescribing doctor Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.: The SOP will be reviewed annually, next review due: It will also be reviewed in the event of any of the following:

 Changes in relevant legislation or recommended guidance

 Following an error or significant event Risks: details of things that could go wrong, how to minimise such risks, and the procedure for recording significant events, e.g.: Errors due to drugs with unfamiliar names/dosages Interactions with other medication Acceptance: Signatures (dated) of relevant staff:

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 7 of 17 SOP: INTERVENTIONS AND PROBLEM SOLVING. Version no. and date Purpose: what the SOP is for, e.g.: To ensure that interventions are dealt with appropriately and promptly, and that patience confidence in the prescriber is maintained Scope: what the SOP covers, e.g.: All interventions and problem for all NHS and private prescriptions Process/procedure: detailed steps which are to be taken, e.g.: If an anomaly is identified: Ask patient if appropriate Check sources of reference (e.g. published reference books – BNF, MIMS etc., or manufacturer’s literature or helpline) Refer to Prescribing doctor Advise patient if there is likely to be a delay, or if items are out of stock Record details; follow Significant Event Reporting procedure where appropriate Responsibilities: who is responsible for what, including delegation and back-up arrangements (e.g. in case of holidays/sickness etc.), e.g.: Dispensing doctor and/or Dispenser

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 8 of 17 Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.: The SOP will be reviewed annually, next review due: It will also be reviewed in the event of any of the following:

 Changes in staffing

 Following an error or significant event Risks: details of things that could go wrong, how to minimise such risks, and the procedure for recording significant events, e.g.: Unable to resolve in reasonable timescale Acceptance: Signatures (dated) of relevant staff:

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 9 of 17 SOP: ASSEMBLY AND LABELLING. Version no. and date Purpose: what the SOP is for, e.g.: To ensure that dispensed prescriptions have been assembled and labelled accurately before being transferred to the patient Scope: what the SOP covers, e.g.: The labelling and assembly of acute and repeat NHS and private prescriptions Note any exceptions. Process/procedure: detailed steps which are to be taken, e.g.: Check source of prescription (electronic or manual) and print labels accordingly Check quantity/length of course Check any drug interaction warnings and seek guidance/record appropriately Check dosage instructions on label are correct and easy to understand Check handing of drugs/protective clothing/cleanliness Select product/check strength/check formulation Check expiry dates If appropriate count out correct number of units and place in appropriate container Follow xxx procedure if insufficient stock Include relevant information leaflets For private prescriptions, calculate price Pass on for checking Responsibilities: who is responsible for what, including delegation and back-up arrangements (e.g. in case of holidays/sickness etc.), e.g.: All Dispensing staff also note arrangements for sickness/holiday cover Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.: The SOP will be reviewed annually, next review due: It will also be reviewed in the event of any of the following:

 Following an error or significant event Risks: details of things that could go wrong, how to minimise such risks, and the procedure for recording significant events, e.g.: Errors due to drugs with similar names or similar packaging Errors due to drugs with unfamiliar names/dosages Acceptance: Signatures (dated) of relevant staff:

SOP: ACCURACY CHECKING. Version no. and date Purpose: what the SOP is for, e.g.:

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 10 of 17 To ensure that dispensed prescriptions have been assembled and labelled accurately before being transferred to the patient Scope: what the SOP covers, e.g.: Covers the way in which prescriptions that have been assembled and labelled are checked for accuracy before passing to patient Process/procedure: detailed steps which are to be taken, e.g.: For each item on the prescription check: > drug name, strength, quantity, form, expiry date, dosage instructions, labelling and label warnings > multiple packs are all the same > leaflets/PILs If correct, tick ‘checked by’ box, place items in bag, annotate special storage requirements and add spoons etc. as necessary. Staple prescription to bag Place bag ready for transfer to patient Record errors and report to Dispenser/Dispensing doctor. Follow Significant Event Reporting procedure where appropriate Responsibilities: who is responsible for what, including delegation and back-up arrangements (e.g. in case of holidays/sickness etc.), e.g.: Dispensary staff Review: how often, or under what circumstances, the SOP is

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 11 of 17 to be reviewed, e.g.: The SOP will be reviewed annually, next review due: It will also be reviewed in the event of any of the following:

 Following an error or significant event Risks: details of things that could go wrong, how to minimise such risks, and the procedure for recording significant events, e.g.: Lack of attention to detail (assumption that it’s correct) Acceptance: Signatures (dated) of relevant staff:

SOP: TRANSFER OF ITEMS TO THE PATIENT. Version no. and date Purpose: what the SOP is for, e.g.: To ensure that patients receive the dispensed items intended for them and with sufficient information to enable them to use the items effectively Scope: what the SOP covers, e.g.: Covers the transfer of all dispensed prescriptions to patients (or their representatives) Process/procedure: detailed steps which are to be taken, e.g.: Call patient and check identity © Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 12 of 17 Check patient understands how to take the prescribed medication and is aware of side effects Check that Parts 1, 2 and 3 on the reverse of the prescription have been completed appropriately/correctly Ensure prescription charge had been paid where appropriate Place prescription for filing and complete registers (Controlled Drugs etc.) Responsibilities: who is responsible for what, including delegation and back-up arrangements (e.g. in case of holidays/sickness etc.), e.g.: All Dispensary staff Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.: The SOP will be reviewed annually, next review due: It will also be reviewed in the event of any of the following:

 Following an error or significant event Risks: details of things that could go wrong, how to minimise such risks, and the procedure for recording significant events, e.g.: Patient identification errors (e.g. popular names like Smith)

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 13 of 17 Patients who are hard of hearing or for whom English is not their first language Acceptance: Signatures (dated) of relevant staff:

British Association Dispensary Services Quality Scheme

BMA - Dispensary Services Quality Scheme, August 2006

Dispensing Doctors’ Association

http://www.dispensingdoctor.org

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 15 of 17 Appendix A follows on the next page >>>Appendix A – SOP template

SOP: name Purpose: what the SOP is for

Scope: what the SOP covers

Process/procedure: detailed steps which are to be taken

Responsibilities: who is responsible for what, including delegation and back-up arrangements (e.g. in case of holidays/sickness etc.)

Review: how often, or under what circumstances, the SOP is to be reviewed Example text: The SOP will be reviewed: Annually, next review due: It will also be reviewed in the event of any of the following:

© Practice Services UK Limited. For use within your practice only. You are not permitted to supply this to any other organisation. Page 16 of 17  Changes in relevant legislation or recommended guidance

 Following an error or significant event Risks: details of things that could go wrong, how to minimise such risks, and the procedure for recording significant events

Acceptance: Signatures (dated) of relevant staff: