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More work needed to monitor controlled drugs, says Commission

5 August 2008

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Practices must ensure that prescriptions for all schedule 2 and 3 controlled drugs are written on the appropriate form so that they can be monitored, a Healthcare Commission report has recommended.

The report outlines the steps that have been taken to improve monitoring of controlled drugs since the Controlled Drugs (Supervision of Management and Use) Regulations came into force in England on 1 January 2007.

It says that more work is needed by NHS and private healthcare providers to ensure that all concerns are picked up, investigated and, where appropriate, action is taken.

The 2007 regulations followed the government’s response to the fourth Shipman Inquiry report, The Regulation of Controlled Drugs in the Community (July 2004), and provide a new legislative structure for the safer management of drugs that are liable to abuse, including narcotics such as diamorphine.

The report states that, since the regulations came into effect in January 2007, healthcare providers have put better mechanisms in place for the management of controlled drugs, including improved documentation and procedures.

However, it also says more work is needed in some areas, and includes the recommendation that doctors, including GPs, must write private prescriptions for controlled drugs on the appropriate form in order that the quantity and type of all schedule 2 and 3 controlled drugs being prescribed privately can be monitored.

The Royal Pharmaceutical Society of Great Britain report that some prescribers remain unaware of the new requirements and the need to use the standardised form.
The report also says local intelligence networks must share information about controlled drug concerns, including concerns related to named individuals, and healthcare professionals who prescribe or administer drugs to patients within care homes must ensure that the care home has a written record of the drugs prescribed and administered, in addition to their own records.

Anna Walker, Chief Executive of the Healthcare Commission, said: “Healthcare services have taken the first steps in minimising the risk of another Shipman. This is important in improving patient safety and it is to be welcomed.

“Much work is still necessary to embed the new networks and ensure that concerns about controlled drugs are picked up, investigated and, where necessary, acted upon. Healthcare managers need to ensure that the networks are working effectively, staff feel able to raise concerns as appropriate and unusual patterns in the use of these drugs are investigated.

“We owe it to Shipman’s victims and their relatives to be vigilant in ensuring that controlled drugs are managed safely and effectively.”

Healthcare Commission

Related article: Controlled drugs inspections in practice premises