If a ward requires an item(s) out of hours they do not have in stock they should take the following actions

1. Use patients own supply if appropriate
2. Attempt to obtain it from the emergency drug cupboard on their site via the locally agreed process. Then if that fails
3. Attempt to borrow it from another ward on their site. Then if that fails
4. The site page holder/response nurse should examine the service wide emergency drug cupboard list to determine if the required item(s) are held in another site’s emergency cupboard. If they are they should then take the following actions
• Contact the page holder/response nurse for the site with the required item(s).
• Explain the need and ask for the items to be made available.
• The page holder/response nurse for the site with the required item will check the emergency cupboard to make sure the items are available and confirm that they will supply them to the unit that needs them.
• On receipt of that confirmation the page holder/response nurse for the site that needs the items will arrange for a taxi to go the site that is lending them.
• The page holder/response nurse for the site with the required item will then take the following steps:
  • Complete local documentation for removing an item from the emergency cupboard as per usual practice.
  • Place the item(s) into a grey plastic envopak (supply available in emergency cupboard) & seal up, write destination on outside of envopak.
  • Fill in consignment note (supply available in emergency cupboard) with date, time & exact address & post code for delivery.
  • Take sealed envopak & consignment note to appropriate reception area (each site will determine the precise location) for uplift by taxi
  • On uplift the taxi driver will be required to sign the consignment note and endorse with their taxi ‘call number’. The white copy of the consignment note will be sent with the goods and the green copy sent to the pharmacy on or associated with the site.
  • On receipt of the package the receiving site nurse will sign the white copy of the consignment note and return it to pharmacy.
  • The receiving unit will confirm the successful delivery of the required items with the lending unit.
• The contents of emergency cupboards will be checked up on a regular basis by local pharmacy technical services.
• Where there are emergency stocks of controlled drugs within Emergency Cupboards, a CD order must be written by the ward requiring these items and it and a copy of the prescription sheet must be provided to the staff releasing stock from the emergency cupboard stock before any supply can be made.
5. Saturday & Sunday 9am - 12noon obtain from the relevant Acute Sector dispensary as follows:
   

   Dykebar, Leverndale, Blythswood House, Darnley Court & Rodgerpark – RAH Pharmacy (Saturday only)

   Birdston, Orchards, Parkhead, Rowanbank,  Gartnavel Royal, Netherton & Stobhill – GRI Pharmacy

   Note:  The ability of mental health wards to obtain medicines from Acute dispensaries on Saturday & Sunday mornings is at the discretion of the dispensary staff. Only medicines deemed as genuinely necessary will be supplied i.e. this is not a service to compensate for poor stock management during the normal working week. Mental Health wards must phone the dispensary first to discuss the need for any medicines required and will be responsible for arranging the transport to collect the required items.

6. Steps 1 – 5 must be undertaken by wards & services before contacting the mental pharmacy on call team via switchboard.

This protocol describes the process for hospital inpatients only.

The following exclusions apply:

• Titrations for newly registered patients
• Supply for outpatients
• Supply for pass or discharge

1. Each mental health hospital emergency drug cupboard will contain an out of hours clozapine pack consisting of

• A copy of this protocol
• 84 x 25mg clozapine tablets
• 84 x 100mg clozapine tablets
• Pre-printed blank labels
• Appropriate containers into which the required quantity must be dispensed
• Out of hours clozapine dispensing record forms

2. Permission to access the clozapine emergency supply stock must be obtained from the mental health on call pharmacist, who can be contacted out of hours via switchboard. Before authorising the supply, the pharmacist will

• Check and confirm the current blood result status
• Identify the required dose
• Determine if there has been a treatment break and advise accordingly
• Ask other appropriate clinical questions to assure it is safe and appropriate to supply
• Advise on the quantity of clozapine to be dispensed which will be determined on a case by case basis. This will be a quantity sufficient to last the patient until at least the next working day on which Leverndale Pharmacy can make a full supply.

3. Once permission has been obtained the nursing duty page holder/response nurse will access the clozapine out of hours pack and dispense the quantity authorised by the on call pharmacist.

4. A clozapine out of hours dispensing form will be completed, scanned and emailed to Leverndale Pharmacy

5. The clozapine out of hours pack will be replenished by routine pharmacy emergency cupboard stock processes.

6. Compliance with this protocol will be audited every 6 months.

Click here for emergency cupboard list.