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The following procedure should be followed to order pass medication for patients,
Document in the patient’s care plan the duration of the pass plus any requirement for ‘as required’ medication.
Complete the first two sections of the pass medication request form in full. This may be done by nursing, pharmacy or medical staff, who should sign the form appropriately. Include details of any 'as required' medicines need plus any special requirements e.g. compliance devices.
If the pass is to be repeated, state how often in the area provided on the request form .
When sections 1 & 2 of the Pass Request Form have been completed, send the form and the patient’s prescription sheet should be conveyed to pharmacy preferably to a secure pharmacy generic email address.
If faxing named prescriptions to pharmacy the criteria described in the NHS GG&C Faxing Policy must be met.
Pharmacy will dispense the patient’s medication and complete in full the pharmacy section of the Pass Medication Request Form.
The dispensed pass medication and a copy of the completed form will be returned to the ward where it will be stored appropriately until required by the patient.
Prior to issuing the pass medication to the patient, a qualified nurse must check the contents of the pass supply against the Pass Medication Request Form and the medicines prescription sheet. The purpose of this check is to pick up any dispensing errors or identify any changes to the patient’s prescription that may have taken place since the pass was ordered. Any discrepancies must be notified to pharmacy immediately and if necessary a new pass medication request ordered using the procedure above. If everything is correct the nurse must sign and date section 4 of the form.
On handing the pass medication supply to the patient or their representative a signature must be obtained. The Pass Medication Request Form should then be filed appropriately in the patient’s notes.
1. Controlled Drugs – The system above may be used for any non CDs on the patient’s prescription. However, CDs required for the pass must be ordered on a separate prescription, compliant with the relevant legislative requirements and written by an appropriate prescriber.
2. Local policy must be followed for any passes dispensed out with normal pharmacy hours.
The form for ordering pass medication can be found here.
Last reviewed: 29 August 2019
Next review: 01 August 2021
Author(s): MH SUM group
Approved By: MH Quality & Clinical Governance Group
Reviewer Name(s): Andrew Walker, Suzanne Burke