Reporting Controlled Drug Incidents
There is a requirement for the Controlled Drug Accountable Officer (CDAO) to be notified of all incidents and concerns involving controlled drugs (CDs).
How to report an incident, please see the forms below:
What to report:
1. Clinical Governance and Professional Practice
• All events or near misses involving prescribing, administration, supply or dispensing of CDs
• Any concern(s) about professional practice or behaviour of staff in relation to CDs e.g. unusual prescribing patterns
• Complaints from patients/carers/service users relating to CDs
2. Record Keeping and Stock Discrepancies
• Unexplained losses/discrepancies of any CD, regardless of schedule
• Any discrepancy in CD stock which, although resolved, raises concerns
• Events or near misses involving CD destruction
• Loss of CD Register/Order Book or other relevant controlled stationery
3. Fraud and Possible Criminal Issues
• Any suspected illegal activity relating to CDs, e.g. theft, patients attempting to obtain CDs by deception
• Lost or stolen prescription forms
• Attempts to fraudulently produce prescriptions. These examples are not mutually exclusive, for example, record keeping issues may escalate to concerns about clinical practice or suspected theft.
Controlled Drug Destruction – Requesting Attendance of Authorised Witness
To request a CD Destruction, please complete the CD Destruction Visit Request form – here
In advance of the appointment, Community Pharmacists should:
- Ensure that all items are recorded in an appropriate CD register
- Check that balances are correct
- Ensure there are no unresolved discrepancies
- Ensure that there are sufficient kits for the volume of CDs requiring destruction
- Have a member of staff available for the duration of the appointment
- Ensure all staff members have the appropriate PPE
Note – There is no legal requirement for patient-returned CDs and pharmacy stock of Schedule 3, 4 and 5 CDs to be destroyed in the presence of an Authorised Witness; the destruction of these must be recorded and signed for in the back of the private prescription book/ patient returned CD register (agreed by the GPhC Inspector).
If you have any questions then please contact the Governance Team via email fife.cd@nhs.scot or telephone 01383 565351
Guidance, References and Resources
- CD Top 10 of things to remember – a thematic analysis of reported incidents in NHS Fife
- A guide to good practice in the management of controlled drugs in primary care – Scotland (Version 2, September 2014)
- A Guide to Good Practice in the Management of Controlled Drugs in Primary Care – Scotland: Summary Document for Community Pharmacists and Registered Technicians
- Form CDRF (CP): Requisition for schedules 1, 2 and 3 controlled drugs (this form should be used for the transfer of Controlled Drug stock between Community Pharmacies)
- The Controlled Drug Accountable Officer (CDAO) Network – Free access available on the Knowledge Hub (KHub)
Legislation
Controlled Drug Team:
Controlled Drug Accountable Officer (CDAO)
Fiona Forrest, Director of Pharmacy and Medicines
Controlled Drugs Governance
Victoria Robb, Lead Pharmacist in Medicines Safety
Ashley Balloch, Specialist Pharmacy Technician for Controlled Drugs
If you have any questions, please contact the Controlled Drug Team at fife.cd@nhs.scot, or telephone 01383 565351 or extension 35351.