Medication in Care Homes 

 

Managing medicines in care homes means that residents should have the same involvement in decisions about their care and treatment and should have the right to access appropriate services and support equivalent to those who do not live in care homes.

If you are based in ‘Herts Valley CCG you will find the most up to date Care Home Medicine Newsletters here.

National Guidance

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Title Info Link
National Institute for Health and Care Excellence (NICE) guideline: Managing medicines in care homes
NICE published this guideline in March 2014; it considers all aspects of managing medicines in care homes and recommends that all care home providers have a medicines policy that includes written processes. The policy should ensure that processes are in place for safe and effective use of medicines in the care home.

NICE Guideline SC1: Managing medicines in care homes
NICE Guideline SC1: Quality Standard
NICE Guideline SC1: Tools and Resources
National Institute for Health and Care Excellence (NICE): Checklist for care home medicines policy
NICE have produced a checklist for health and social care staff on developing and updating care home medicines policies. It gives more information about the processes that should be covered.

NICE: Checklist for care home medicines policy
Care Quality Commission (CQC) learning from safety incidents: Issue 5: Safe management of medicines
The ‘Learning from safety incidents’ resources have been developed to share common critical issues identified from CQC’s criminal prosecution work against providers that have failed to provide care and treatment in a safe way.

The ‘safe management of medicines’ resource includes prescribing, handling and administering medicines. Health and social care staff often manage medicines on behalf of people using their services. Providers must promote the safe and effective use of medicines in care homes.

CQC learning from safety incidents: Issue 5: Safe management of medicines
CQC Medicines: information for adult and social services
Information provided by the CQC on different medication regarding high-risk medications, storage, oxygen, administering and much more...

https://www.cqc.org.uk/guidance-providers/adult-social-care/medicines-information-adult-social-care-services
Medicines PIL
All recent updates of medication in one place

https://www.medicines.org.uk/emc
National care forum meds safety resources
Free resources for supporting the safe use of medications in care facilities

http://www.nationalcareforum.org.uk/medsafetyresources.asp
Care homes Use of Medicines (CHUMS)
Study: Medication errors in nursing & residential care homes ‐ prevalence, consequences, causes and solutions Report to the Patient Safety Research Portfolio, Dept of Health

https://www.birmingham.ac.uk/Documents/college-mds/haps/projects/cfhep/psrp/finalreports/PS025CHUMS-FinalReportwithappendices.pdf

Local Policy and Guidance

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Pregabalin and Gabapentin will be classed as Schedule 3 controlled drugs from 1st April.

Introduction

The reclassification follows Government consultation and recommendations from the Advisory Council on the Misuse of Drugs for additional safeguards to be put in place because of concerns around the misuse of these drugs. However, pregabalin and gabapentin will be included in the list of “exempted drugs” in the safe custody regulations which means that care homes will not be required to keep these drugs in the CDs cabinet.

Prescription requirements

From 1st April 2019, all gabapentin and pregabalin prescriptions will be subject to the following prescription writing requirements for Schedule 3 CDs:

  • Patient name and address
  • Prescriber’s address
  • Prescriber’s signature
  • Date of prescriber’s signature
  • Drug name, strength and formulation
  • Dose (Note: ‘as directed’ is NOT acceptable; ‘one as directed’ is acceptable)
  • Total quantity (in both words and figures)

Further guidance can be found here

Please note: Care Homes will still need to sign for them when delivered or collected from pharmacy

Residents in care homes who need an over-the-counter (OTC) medicine

 

Following the results from a  public consultation in 2017, East and North Hertfordshire CCG implemented a policy that medicines that can be bought over-the-counter to treat minor illnesses and short-term conditions will no longer be routinely prescribed by GPs.  The same policy is also in place in the Herts Valleys CCG area and NHS England has issued national guidance on conditions for which over the counter items should not be routinely prescribed in primary care.

People are advised to purchase these medicines when they are needed and obtain advice from a pharmacist who has the clinical expertise to help them to manage their symptoms.

Good Practice Guidance Prescribing Over the Counter Medication – Herts Valleys

Good Practice Guidance Prescribing Over the Counter Medication – East and North Herts

Please click here to read full guidance covering- exception criteria and guidance.

If your care home does not have a ‘homely remedy’ policy in place, please contact your local CCG pharmacy team and who will advise you:
East and North Herts CCG: 01707 685207
Herts Valleys CCG pharmacy team: 01442 898888

Homely or household remedy is another name for a non-prescription medicine which is used in a care home for the short term management of minor, self-limiting conditions. Minor conditions will include conditions such as cold symptoms, headache, occasional pain or indigestion.

This guidance aims to ensure that access to treatment for minor ailments is as it would be for a patient living in their own home.

They can be obtained without a prescription and are usually purchased by the care home or sometimes by the resident.

» Please click here to read the guidance (Herts Valleys)

» Please click here to read the guidance (EN Herts)

A bulk prescription is an order for two or more patients, bearing the name of a school or institution e.g. a care home, in which at least twenty persons normally reside, for the treatment of at least ten of whom a particular doctor is responsible.

A bulk prescription allows care home staff to use the same supply of a medication for all residents who are clinically identified as suitable for the prescribed medication.

 

Read HVCCG guidance here

To provide guidance for care home staff regarding the covert administration of medicines to adults and older people in care homes.

» Covert Administration of Medicines for Care Homes in West Herts

» Covert Administration of Medicines Policy for Care Homes in East and North Herts

In order to minimise the risk of cross-contamination please be aware:

 

 Plastic pots should only be used for liquids and are also SINGLE USE. Pots should NEVER be washed and re-used.

 Paper SINGLE USE pots should be used for tablets ONLY and should be discarded after each use.

plastic spoon should also be regarded as single use and disposed of after each use.

Community pharmacists are not obliged to supply medicine pots for medicines administration.  Care homes can order medicine pots from various suppliers (approx £3.78/250 waxed paper pots,  £2.39 /80 plastic pots)

Different types of medicines are available in patch form; some include painkillers, medicines to treat Parkinson’s disease, and medicines to control nausea and vomiting. We would like to provide care home staff with some information relating to the use of patches in care home settings.

Application of Patches

The interval between patches can vary. Patches should be applied at the frequency determined by the prescriber.
The site of application should be rotated with each application in accordance with the manufacturer’s instructions. The manufacturer may recommend that the same site should be avoided for a certain length of time. This varies from patch to patch. Always check the patient information leaflet.
Patches should not be applied immediately after a person has had a bath or shower, as heat can increase the absorption of some medicines into the bloodstream.
Old patches should be removed, folded in half and safely disposed of, before applying a new patch.

Record keeping

The application of a patch should be recorded on the MAR chart.
The specific location of the patch should also be recorded. This may be on the MAR chart if there is sufficient space or using another template e.g. a body map or a patch chart.
When a patient is transferred between settings, staff should ensure that information around the date, time and site of application, are communicated.

In the first instance consider how essential the medication is and whether alternative formulations (e.g. liquids, patches or sublingual tablets) or medications can be used.

Before a person crushes or opens a medication, a pharmacist should always be consulted to find out if this is possible and this should be approved by the prescriber and documented in patient records.

There are some tablets and capsules that should never be crushed or opened such as enteric coated, modified release preparations, hormone, steroid, antibiotic or chemotherapy (cytotoxic) medicines without appropriate advice from a pharmacist.

Liquid medicines ordered from specials manufacturers are unlicensed and often very expensive. Additional patient monitoring may be required which the pharmacist will advise on.

Guidance

Tablets and capsules are the most commonly prescribed formulation of medicine. However, some care home residents may have difficulties with swallowing and so cannot use tablets or capsules in their wholesale form. In these circumstances, decisions have to be made about whether the medication needs to be continued or if there is an alternative treatment available.

 

Download ENHerts CCG guidance here

Download HVCCG Guidance Here

Methotrexate is a powerful cytotoxic medication and should be treated with great care. At the right dose and with appropriate monitoring, it is safe and effective for use. Methotrexate is a disease-modifying drug and affects how the body’s cells grow and reduce the activity of the immune system. It is therefore important that all care home staff involved in the administering of medicines or the handling of body fluids are provided with the appropriate training to ensure they are aware of the associated risks.

Methotrexate is used to treat severe psoriasis, rheumatoid arthritis or Crohn’s disease or in larger doses to treat certain types of cancer.

 

Download guidance here

Click here for information on how to order online

Each resident will be issued with a unique Account ID (user ID) which should be saved securely in the residents care plan. Please note, any resident whom has agreed to their medical record to be on EMIS Access cannot be included for ‘online ordering’.

Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients

Warnings about the risk of severe and fatal burns are being extended to all paraffin-based emollients regardless of paraffin concentration. Data suggest there is also a risk for paraffin-free emollients. 

 

View further information

What is NOAC?

These are a group of novel anticoagulants which helps reduce the risk of clots in a number of indications, see below for further information. These are an alternative to warfarin and NOACs include – apixaban, edoxaban, dabiagatran and rivaroxaban.

Common uses:

  • Atrial Fibrillation (AF)
  • Recent hip or knee replacement
  • Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

Download further guidance here

Step 1: Care Home Placement
Care Home agrees placement of a person at care home following assessment in a hospital, other home or their
own home.
Note: If transfer is from an acute hospital then two weeks medication will be supplied – information on
medication should be requested from the hospital on transfer to ensure a MAR sheet is prepared.

Step 2: Care Home Transfer Arrangements
Prior to arranging transfer, the Care Home must confirm GP registration for the individual.

Step 3: Care Home Register with New GP

Read more…

Falls and fall-related injuries are a common and serious problem for older people. People aged 65 and older have the highest risk
of falling, with 30% of people older than 65 and 50% of people older than 80 falling at least once a year.

Residents who have fallen are at high risk of a repeat fall.

Download a list of medications that can contribute to an increased risk of falls (ENHerts)

Download a list of medications that can contribute to an increased risk of falls (HVCCG)

Learn more about HCPA’s StopFalls Campaign

The recording of drug sensitivity/allergy is important to avoid the inadvertent prescribing, dispensing and administration of an offending drug to the resident. Care home residents are a frail and vulnerable population who are at high risk of adverse drug reactions. There are large discrepancies between drug allergy records, residents care home records, medicines administration record charts and GP medical records. Furthermore, there is no routine system in place for people to keep a record of their own drug sensitivities / allergies. This can lead to confusion over which drugs can be taken safely and can result in residents inadvertently taking a drug they are allergic to.t settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.

Read full ENHerts CCG guidance here

Read full HVCCG guidance here

Education and Competencies

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Please visit HCPA’s training page to see what medication training HCPA and the County Council are delivering, you will also find information on how you can claim mandatory funding for medication training at your service.

Click here to view HCPA’s Training Page

Click here for HCPA Members Network Event Presentation for further information on medication and nutrition

Although, HCPA does not endorse e-learning as quality training (click here for the Hertfordshire Blended E-Learning Policy). We have been advised of the below medication e-learning from PrescQIPP which you could use to enhance face-to-face training.

PrescQIPP

The Hertfordshire clinical Commissioning groups have funded the use of PrescQIPP E-learning package for Care Home staff across the County. As you will be aware E-Leaning is not considered good enough by itself and should be accompanied with Face to face training and monitoring of competencies to form a Blended Learning Package.

Please read a copy of HCPA E-Learning Guidance here

To gain login details please follow the guidance that can be found here.

Medicines Use in Care Homes Course 1 e-learning Medicines Use in Care homes: Course 2 e-learning pdf


The Care Homes 1 e-learning package is aimed at all care home staff involved with managing medicines. It is the first of several-planned e-learning packages for Care homes and will include the following modules in addition to three case studies to help apply learning to practice.

> Module 1 - Welcome and introduction
> Module 2 - The role of CQC and the NICE guideline and quality standards
> Module 3 - The management of medicines in care homes
> Module 4 - Management of self-medicating residents
> Module 5 - Administration of inhalers
> Module 6 - Administration of eye drops
> Module 7 - Administration of transdermal patches
> Module 8 - Administration of topical products
> Module 9 Administration of PRN medicines

Further information about the course and how to access the course is included in the flyer available here.

The Care Homes -2 e-learning package builds on the content covered in the Medicines use in care homes: Course 1 and includes 7 modules focusing on key topics, in addition to three case studies that will help apply learning to practice

> Module 1 - Welcome and introduction
> Module 2 - Refused and omitted doses
> Module 3 - Covert administration
> Module 4 - Managing controlled drugs
> Module 5 - Bulk prescribing
> Module 6 - Homely remedies
> Module 7 - Medicines waste reduction

Further information about the course and how to access the course is included in the flyer available here.
Advanced Medication Champion Pathway
New dates to be published

This pathway based on Hertfordshire County Councils medication policy and competencies is designed to upskill your staff member in understanding best practice and techniques, recognising wastage and polypharmacy, risk assessments and linking with other professions. Upon completion, the Champion will receive Level 3 delivering training qualification, a Level 3 unit in medication, an assured course in coaching and mentoring, and obtain a Train the Trainer toolkit in Medication, so knowledge and practice can be cascaded down to staff teams.

Reviews

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A medication review is a chance for your GP (doctor) and a specialist pharmacist to take a detailed look at the medicines that you are taking, to make sure that they are working well for you and are not giving you any problems.

Medication reviews are particularly useful for people who take lots of medicines as they can be at greater risk of having a bad reaction and needing to be admitted to hospital.

Also, as you get older, some of the medicines you have been taking for a while might become less important. For example, if you are over 80 you might not be too concerned about reducing your risk of a heart attack in twenty years’ time and you might not want to have muscle aches, constipation and poor sleep which are potential side effects of statins ‐ common cholesterol lowering drugs.

Read more...

Deprescribing

  • The number of medicines patients are taking is increasing, driven by the ageing population, multiple prescribers and evidence-based guidelines (usually based on single conditions).
  • For many patients, the potential harms of multiple medicines outweigh the potential benefits, reducing life expectancy and quality of life.
  • Older people and those with increasing frailty are frequently prescribed unnecessary, or higher risk medicines, they should have more frequent medication reviews.
  • Deprescribing is the planned process of reducing or stopping medications that may no longer be of benefit or may be causing harm.
  • The goal is to reduce medication burden or harm while improving quality of life, thus ensuring appropriate polypharmacy and improving patient outcomes

 

What happens during a medication review?

Your GP and pharmacist will look at the medicines you take.

They will consider whether:

  • there has been a change in your health or the guidelines on how to treat your condition
  • you are able to take your medicines without difficulties
  • you are taking any unnecessary medicines
  • there is a different medicine which will be just as effective but cheaper for the NHS

Your GP and pharmacist will look at the medicines you take.

They will consider whether:

  • there has been a change in your health or the guidelines on how to treat your condition
  • you are able to take your medicines without difficulties
  • you are taking any unnecessary medicines
  • there is a different medicine which will be just as effective but cheaper for the NHS

 

Following a review –

What happened next:

Once the team has reviewed your medicines, any changes that are needed will be made slowly and gradually. We will make sure you are told about which medicines are being changed and can answer any questions you may have.

Changes might be:

  • how often you take medicines – for example, taking a tablet once a day rather than three times a day
  • you might start a new medicine or change to a different version
  • a medicine being stopped because you no longer need it.

Download the medication review leaflet here.

To find out more please contact your local CCG Team:

Herts Valleys CCG
Hemel One
Boundary Way
Hemel Hempstead
Hertfordshire
HP2 7YU

http://hertsvalleysccg.nhs.uk

East and North Hertfordshire CCG
Charter House
Parkway
Welwyn Garden City
Hertfordshire
AL8 6JL

http://www.enhertsccg.nhs.uk/

Ordering and Waste Reduction

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The care home pharmacy team at Herts Valleys CCG, and East and North Herts CCG, have developed guidance on reducing medicines waste in care homes. The guidance contains key top tips to support care home staff and prescribers to reduce unnecessary medicines waste in care homes, and also includes expiry date guidelines for care home staff. It is important that there are effective systems and processes in place to ensure that medicines are managed appropriately to reduce avoidable medicines waste, and therefore to allow effective use of NHS resources.

The guidance can be found via the following link for  CCG guidance. Many factors can contribute to medicines waste in care homes, and a joint effort involving the care homes, community pharmacies and GP practices required. The guidance has been sent to all GP practices and community pharmacies within Herts Valleys CCG. Please share this guidance with all relevant staff within your care home.

For information on the medication, ordering cycle click here.

We can help save money in care homes by….

  • Only ordering what is needed
  • Ordering ALL residents’ medication at the same time
  • Ensuring medicines started mid cycle are synchronised
  • Ensuring at least two members of care home staff have the training & skills to order medicines
  • If residents continually refuse to take medicines discuss with GP before re-ordering
  • Asking the community pharmacy to remove discontinued medicines from MAR
  • Knowing your expiry dates
  • Making sure your community pharmacy issues EPS tokens before medication is delivered

UTI’s and Hydration

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“To Dip or Not To Dip?”

Improving the quality of UTI care by working together across Hertfordshire

National Guidelines:

“People >65 years should have a clinical assessment before being diagnosed with UTI” (NICE)

Do not use urine dipstick testing in the diagnosis of older people with possible UTI” (SIGN)

Do not use dipstick testing to diagnose UTI in adults with urinary catheters” (NICE)

Prevention is better than cure!

Prevent dehydration = Prevent UTIs 

Cause Effects
Forget to drink Puts strain on the kidneys
Sense of thirst lessens with age Bacteria not flushed out of bladder regularly
Warm environment Causes constipation
Longer periods sitting down Makes it harder for body to fight infection
Continence Increased risk of UTI

Ensure residents are drinking
1.5 – 2 litres of fluids per day*

*Some residents may have been advised to restrict fluid intake if they have a heart or kidney condition. Discuss with GP or Matron if unsure.

Nutrition

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Local guidance

Subject Description Links
Adult sip feeds (ONS) in primary care A quick reference for health and care professionals (including care home staff) regarding identification and treatment of malnutrition in the community. It contains links to all other ‘food first’ documents on the CCG website, in addition to essential guidance on when it is (and is not) appropriate to prescribe ONS and the most cost effective ONS to prescribe.

  • Malnutrition should be identified using the Malnutrition Universal Screening Tool (MUST) before treatment is commenced (medium or high risk = malnourished)
  • Treatment of malnutrition should start with a ‘food first’ approach using the resources below
View the Managing Malnutrition Pathway

http://hertsvalleysccg.nhs.uk/publications/pharmacy-and-medicines-optimisation/local-decisions/nutrition-and-blood/ons/6177-adult-ons-prescribing-in-primary-care-quick-guide/file
Food First – Eating well for small appetites A self-explanatory leaflet designed for patients at medium or high risk of malnutrition according to MUST. It focuses on enabling patients to increase their nutritional intake by at least 500 calories per day and can be given out by any healthcare professional without additional explanation http://hertsvalleysccg.nhs.uk/publications/pharmacy-and-medicines-optimisation/local-decisions/nutrition-and-blood/ons/4487-food-first-eating-well-for-small-appetites/file
Food First – Quick guide A short version of the above leaflet. It demonstrates how an additional 500 calories can be consumed simply by making 3 or 4 small dietary changes each day
http://hertsvalleysccg.nhs.uk/publications/pharmacy-and-medicines-optimisation/local-decisions/nutrition-and-blood/ons/4491-food-first-how-to-increase-food-intake-by-500-calories-per-day/file

Food First - Homemade supplements Designed for patients at high risk of malnutrition according to MUST and should be provided together with ‘Food first – Eating well for small appetites’. It is equally suitable to be used for patients living in their own homes or in care homes http://hertsvalleysccg.nhs.uk/publications/pharmacy-and-medicines-optimisation/local-decisions/nutrition-and-blood/ons/4488-food-first-homemade-milkshakes-fruit-drink-and-dessert/file
Eating and drinking at end of life
A self-explanatory leaflet designed for the relatives and carers of people who are reaching the end of their lives. It has been requested by a number of GPs and Dietitians, in order to help reassure carers that loss of appetite and reduction in food intake is a normal and expected part of the dying process and that prescribed nutritional products are unlikely to be appropriate at this stage.

http://hertsvalleysccg.nhs.uk/publications/pharmacy-and-medicines-optimisation/local-decisions/nutrition-and-blood/ons/4489-food-first-patients-receiving-palliative-care/file

Food First

Fortifying food is a brief practical guide for Care Home cooks/chefs on how to fortify food for residents at medium or high risk of malnutrition according to MUST. It guides cooks/chefs to use fortifiers which contain more than just fat, and to use an adequate amount of each fortifier so that this counts towards intake of an additional 500 calories per day. For more details about fortifying food click here




Ways to adapt the recipe Energy Kcal (calories)
Food 1 Portion Adapt by: Before After
Milk 1 pint Add 4 heaped tablespoons dried skimmed milk powder (DSM) to 1 pint whole milk 375 774 (106% extra)
Custard
Large ladle (125mls) Add 1 heaped tablespoon DSM powder & 2 tablespoons double cream to custard made with whole milk 140 340 (143% extra)
Soup Large ladle (125mls) Add 1 heaped tablespoon DSM powder & 2 tablespoons double cream 80 280 (250% extra)
Porridge Large ladle (125mls) Add 1 heaped tablespoon DSM powder & 2 tablespoons of double cream to porridge made with whole milk 170 370 (118% extra)
Mashed Potato 1 scoop Add an extra heaped teaspoon of margarine / butter and tablespoon of cream to mashed potatoes 70 190 (170% extra)
Vegetables 2 Tablespoons Add 1 heaped teaspoon of margarine / butter to vegetables. Allow to melt. 15 85 (460% extra)
Ice Cream 1 Small Scoop Pour 2 tablespoons of double cream over ice cream 100 200 (100% extra)
Sponge Pudding 2 Tablespoons Place an extra 2 teaspoons of jam or syrup on the sponge when serving. Serve with a high calorie custard or ice cream 340 540 (58% extra)
Breakfast Cereal Small serving (25g) Use fortified milk with 2 tablespoons of double cream and 2 teaspoons of sugar 200 430 (115% extra)
Milk Pudding Large ladle (125mls) Add 1 heaped teaspoon DSM powder & 2 tablespoons double cream to the milk pudding made with whole milk. Serve with 2 teaspoons jam 200 500 (150% extra)

Wound Formulary

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Pressure Ulcers also known as pressure sores have occurred since time began and can affect people all over the world.  They are a cause of pain, embarrassment, loss of independence, poor quality of life, depression, social isolation and distress as well as being potentially life-threatening (Keen, 2009).

Pressure ulcers cost a lot of money and can be an expensive drain of the care providers funding with the cost increasing with the severity of the pressure ulcer.  For example, a category 1 ulcer can cost £1, 214 and a category 3-4 can cost between £9,000 and £14, 000 (Dealey et al, 2012).

The UK government aims to eliminate harm resulting from an avoidable hospital and community-acquired pressure ulcers in 95% of NHS patients (Department of Health, 2012).

Pressure ulcers are a problem that affects people of all ages and all healthcare settings

Please click here for updated Pressure Ulcer Policy

 

Risk Assessments and Equipment

» Pressure Ulcer Trigger- Resource

 

Formulary

 

This formulary has been developed to assist any healthcare professional prescribing or requesting dressings for wound management in Hertfordshire. It aims to aid the decision-making process and help choose the most appropriate product whilst ensuring value for money in the use of NHS resources.

Key Messages:

  • All the products in the formulary have been selected taking into account available supporting clinical evidence by a panel of trust wide practitioners who have specialist knowledge and expertise in wound care.
  • Advice in the comments column should be followed when selecting products
  • The formulary contains specific sections dedicated for use in podiatry and the leg ulcer service
  • To avoid waste do not prescribe or request excessive quantities or issue for long term repeats. A maximum of 14 days’ supply should be sufficient.
  • If wound healing does not progress as expected, advice from the Tissue Viability Service should be sought.
  • Dressings prescribed on FP10 for individual patients must not be used for any other patient or for car boot stock.
  • Adherence to the wound products formulary will be monitored and audited. Clinical justification will be required for requesting ‘off formulary’. Exception forms must be completed and sent to Tissue Viability.
  • Where there may be a number of different health professionals visiting a patient, efforts should be made to avoid over ordering by ensuring that there are not multiple orders/prescriptions generated for the same dressings.

  » Click here to download the Hertfordshire Formulary Document 2016

  » Dressing Exception Form

  » Dressing Order Form

 

React to Red Skin

A pressure ulcer prevention campaign that is committed to educating as many people as possible about the dangers of pressure ulcers and the simple steps that can be take to avoid them.

http://www.reacttoredskin.co.uk/

 

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