Controlled Drugs Accountable Officer

Question 1

What does a CDAO do

Answer 1

The CDAO has a responsibility in law to ensure that CDs are managed and used safely

We want healthcare staff to be supported to be open about mistakes to allow valuable lessons to be learnt so the same errors can be prevented from being repeated

Question 2

Why do we only focus on CDs

Answer 2

Medication incidents involving other medicines are just as important and we must learn from those too
Controlled Drugs are controlled by further regulation not just because of the harm they cause, but also because they are addictive

Question 3

What does the CDAO do

Answer 3

They’re a source of advice and support
We review reported incidents involving controlled drugs and seek assurance that these have been investigated, reflected upon, learned from, and action taken to reduce the chance of it happening again
We share information and learning via our ‘Local Intelligence network’
Authorising witnesses for destruction of CDs
Monitoring NHS and private CD prescribing

Question 4

What is the local intelligence network

Answer 4

A network which shares intelligence and concerns about healthcare professionals who may be harming themselves or others by misusing controlled drugs

Question 5

Who is involved in the local intelligence network

Answer 5

NHS England, NHS trust Accountable Officers, private hospital AOs, CQC pharmacists, Counter Fraud staff, GPhC inspectors, police CD Liaison Officers amongst others

Question 6

What is a designated body

Answer 6

Hospital, hospice, private hospital. They all need an accountable officer

Question 7

What are common incidents reported to cdaos

Answer 7

Mostly from community pharmacies
Most involve substance misuse dispensing
One key theme involves supplying medication to the wrong patient. This concerns us:
The risk of harm is high
The rate of recurrence is high
There is a need for vigilance in the handout (supply) stage of dispensing

Question 8

What should be included in a good incident report

Answer 8

Report the incident promptly - has anyone been harmed?
State the facts - what happened? Be open and honest
Who was involved?
Have you explained what has happened to any patients involved and apologised if appropriate?
Tell us why you think it happened
Tell us what you have done to try to prevent it from happening again
What have you learnt as a result by reflecting on what happened? Have you shared this with your team?
How will you check that the change in your practice is working?

Question 9

When would a cd breach incur ramifications

Answer 9

The CDAO wants to help you when things go wrong
That includes helping you investigate, helping you reflect, helping you learn, and helping you to prevent it from happening again
If anything doesn’t sound right, we will ask you
If we know something is wrong we will tell you
In the few very exceptional cases where people are deliberately or regularly causing harm we will take steps to protect patients – and protect the person doing it too.
As a professional you must report concerns

Question 10

What are the most common errors in CD prescribing

Answer 10

Administration errors
Bagging and checking
Diverting of CDs - staff illegally removing stock from the pharmacy and selling it
Delivery errors
Pack size errors
Wrong strength
Mixing up DTF methadone solution with Sugar Free
“Must have thrown it away by mistake”
Number of instalments on an FP10MDA form
“We’ve lost the script” - patient has ‘lost’ their script
Calculating balance discrepancies for liquid stock

Question 11

Case study:
Supplying methadone
John is prescribed 40ml
Jane is prescribed 80ml
If John is given Jane’s methadone in error
What will you do?

Answer 11

Prioritise the welfare of the patient
Explain to them what has happened (duty of candour) - apologise
Notify the prescriber
Not possible? Call NHS 111

Document what you’ve done & report to CDAO
If you have any doubt about whether the patient will seek medical attention you can request that the police check on their welfare and encourage them to get help by contacting the police (e.g. on 101)

Question 12

How is the CD reporting system beneficial

Answer 12

We can track both patients and professionals who are abusing CDs all across the country. Each incident is risk scored and checked by the CDAOs

Question 13

What is the ‘3 day rule’ with FP10MDA

Answer 13

• Contact the prescriber (and case worker) if a patient has missed three days’ doses of an instalment prescription
• The prescriber needs to decide what to do, and will need to assess the risks
• The prescriber may choose to continue, but may reduce the dose and provide a new prescription
• If you cannot contact the prescriber, do not supply a dose – do not risk harming the patient
• You will not be criticised for with-holding the dose if you can’t contact the prescriber

Question 14

How do you spot fraudulent prescriptions

Answer 14

Handwritten prescriptions for CDs should be treated with extreme caution

CD shoudn’t be written on it

You should never see handwritten prescriber details on an FP10 (not illegal, but exceptional)

NB: you do see rubber stamps on yellow FP10D

Question 15

What do you do if you encounter a fraudulent prescription

Answer 15

Contact the prescriber to confirm if it is genuine
If not, keep the prescription as evidence
Contact Counter Fraud (pharmacy get a £70 reward!)
If it is a CD, contact the CDAO
Fraud is a crime – report to police on 101

Question 16

What should you do if you get a script prescribing a suspiciously high dose

Answer 16

Prescribers should expect such doses to be queried
Pharmacists should be challenging scripts for large amounts
The CDAO would also like to be informed
The GPhC expect you to query it with the prescriber

Question 17

What is a ‘high dose’ of opioids

Answer 17

With opioids, any dose higher than the equivalent of 120mg morphine daily counts as a high dose unless you know the patient is at the end of their life (i.e. end stage palliative care)