Dispensing outwith pharmacy hours

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Pharmacy services operate to office hours (8.30am - 4.30pm Monday to Friday). Where possible all prescriptions should be dispensed by pharmacy. However there may occasionally be circumstances where pass or discharge prescriptions are required outwith pharmacy hours. This procedure describes the processes that must be followed to ensure this undertaken safely.

  1. During normal pharmacy hours (Monday to Friday 8.30am to 4.30pm) all prescriptions must be dispensed by Pharmacy. Pharmacy departments have a cut of time of 2:30pm for prescriptions to ensure delivery before the end of the working day. If medication is being requested after this time, the pharmacy should be contacted to discuss whether they are able to fulfill the request.
  2. Containers (bottles or plastic bags) and labels for dispensing outwith hours will be kept in emergency cupboards or appropriate wards on each site.
  3. Prescriptions should only be dispensed outwith hours if authorised by a senior charge nurse, site duty page holder or a doctor.
  4. The nurse will obtain the appropriate amount of containers and labels (one container and one label per item). The number of containers and labels issued should be noted on the out of hours issue form for audit purposes.
  5. The precise number of doses required of each medicine will be dispensed from ward stock into the appropriately labelled container.
  6. A label for each item must be completed with the name, strength, form and quantity of the medicine; clear dosage instructions; the patient’s name and the date of supply. Each label will be written in indelible ink.
  7. Two suitably experienced registered nurses, band 5 or above, must complete the "dispense" and "check" section of each label.
  8. The details of all medication supplied must be recorded on the patient’s prescription recording sheet and on an out-of-hours pass form and filed in the integrated health record 
  9. The nurse will discuss the prescription with the patient and/or carer to ensure that they know why the medicine has been prescribed; when and how to take the medication; details of any potential side effects and adverse reactions; advice on what to do if a dose is missed. Details of this discussion, the authorisation for the pass and the agreed pass period must be recorded in the patient’s integrated health record.
  10. The maximum period of any out-of-hours pass must not exceed 72hours.
  11. This procedure is for use in exceptional circumstances only.


Out of hours pass medication issues form

Details of any prescriptions dispensed out of hours should be recorded on the form in the full procedure.

Editorial Information

Last reviewed: 15 July 2020

Next review: 01 June 2023

Author(s): Safer Use of Medicines- Mental Health

Version: 1

Approved By: PMG-MH

Reviewer Name(s): Andrew Walker, Suzanne Burke