You can view all medicines management procedures by visiting the Policies and Procedures section of YourSpace and selecting Trust Wide (for aligned procedures) or the relevant former Division from the drop down bar, and search with the relevant key word.
If a procedure cannot be found for a former Division, check that this has not been superseded by a Trust wide policy/procedure.
Former divisional procedures may also be found on:
- SharePoint - Local / Secure / LD (now known as Secure Care and Mental Health Care)
- SIRS - Community Division Services (now known as Community Care)
A list of Trust Wide procedure can be found on the Trust Wide Medicines Related Policies and Procedure tab below.
The policies and procedures listed below are available here.
Trust Wide procedures
MMP01 Safe Management of Controlled Drugs
MMP02 Safe Management of Unidentifiable and Suspected Illicit Substances
MMP03 Administration of Discretionary Medicines
MMP04 Overt and Covert Administration of Medicines in Food/Drink (Inpatients)
MMP05 Self Administration of Medicines (SAM) Scheme
MMP06 Transport, Transfer and Collection of Medicines - expected December 2024
MMP07 Medicines Reconciliation for Inpatients
MMP07a Medicines Reconciliation for Patients in the Community
MMP08 Administration of Medicines (inc. Self Administration of Medicines)
MMP09 Safe Use of Injectable Medicines
MMP10 Management of Community Prescriptions - expected December 2024
MMP11 Discharge Medicines Services (DMS)
MMP12 Use of Buprenorphine Injection (Buvidal)
MMP13 Reducing Harm from Omitted or Delayed Time Critical Medicines
MMP14 Zuclopenthixol Acetate Guidelines and Procedure
MMP15 Administration of the Covid-19 and Seasonal Influenza Vaccination to Trust Inpatients
MMP16 Alcohol Detoxification - expected Nov 2024
MMP17 Medicines Management in Special Schools
MMP18 Safe Prescribing of Established Methadone / Buprenorphine
MMP19 Transcribing of Medicines in Approved Services
MMP20 Management of Buccal Midazolam
MMP21
MMP22 Take-Home Naloxone (Addictions Services) - expected Dec 2024
MMP23 Safe Use of Valproate
MMP24 Safe Use of Clozapine
MMP25 Patient's Own Drugs
MMP26 High Dose Antipsychotic Therapy (HDAT)
MMP27 Management of Medicines Errors - expected Sept 2024
MMP28 Management of Thickening Agents in SALT Teams for Assessment
MMP29 Management of Anticoagulation Therapy
MMP30 Medical Gases Procedure (associated with SD59) - expected Dec 2024
MMP31 Transfer of Inpatient Medicines Records
MMP32 Medicines Management at Huyton CoRe and Cluster
MMP33 Ordering, Receipt and Storage of Medicines
MMP34 Handling and Management of Covid-19 and Influenza Vaccines in and within the Trust
MMP35 Business Continuity
MMP36 Medicines Management in GP Support Services
MMP37 Management of Anticipatory Medicines for End of Life Care in Community Childrens Nursing Team
MMP38 Safe Use of Opioids
MMP39 Use of Unlicensed / Off-label Medicines
MMP40 Administration via a Nasogastric Tube
MMP41 Medicines Management in Knowsley Treatment Rooms
MMP42 Prescribing (Inpatients)
MMP43 Safe Use of Potassium Permanganate
MMP44 Medicines Management at Wavertree Bungalow
MMP45 Administration of Medicines by Health Care Support Workers
MMP46 Medicines Management in the IV Therapy Team
MMP47 Administration of Vaccines by trained Health Support Workers and Registered Nurses delivering GP Vaccination
MMP48 Carrying out Safe and Secure Medicines Audit Spot Checks
MMP49 Pharmaceutical Waste
MMP50 Rapid Tranquillisation
MMP51 Treatment of Anaphylaxis
MMP52 Medicines Management in Care Homes - expected Nov 2024
MMP53 Medicines Management in the ICRAS Team - expected Nov 2024
Trust Wide Policies
SD12 Safe and Secure Medicines
SD12A Covid-19 Vaccine Handling and Management
MCT08 Controlled Drugs
MM05 Non Medical Prescribing
SA50 Patient Group Directions
SD59 Safe Management of Medical Gases - expected Dec 2024
The procedures below are service specific and are applicable to the Medicines Management Team only:
- MMT01 Controlled Drugs Audit Procedure
- MMT02 Safe and Secure Medicines Audit
- MMT03 Branded Medicines Request
- MMT04 Dealing with Temperature Excursions
The procedures below are applicable to the Medicines Management Department only and can be found on the S: drive > 'Pharmacy' Folder:
- MMD01 Receiving Outpatient Prescriptions and Dealing with Pharmacy Correspondence
- MMD02 Printing Inpatient Requests on RXSELECT
- MMD03 Printing Outpatient, Repeat, TTO and STL Prescriptions
- MMD04 Labelling Outpatient Prescriptions, Repeat Prescriptions, EPMA STL and TTO Prescriptions
- MMD05 Dispensing Prescriptions
- MMD20 VBM Procedure
- MMD21 Transport and Delivery of Medicines Procedure
- MMD23 Supply of Clozapine Procedure
The procedures below are applicable to the Medicines Management Clinical Trials Team only:
- MMCT01 Access to the Pharmacy Clinical Trials Room
- MMCT02 Temperature Monitoring of IMP
- MMCT08 Pharmacy Site File – Set Up and Maintenance
- MMCT09 MMCT09 Preparation, Review and Approval of Pharmacy Trial-Specific Instructions
- MMCT10 Clinical Trials Staff Training V2
- MMTCT11 Storage and Receipt of IMP
- MMCT19 Writing Clinical Trials SOPs
- MMCT20 Maintenance of Pharmacy Clinical Trials Room (Hollins Park)
- MMCT36 Storage and Collection of IMP
EPMA User Guides / Procedures can be found here on the Medicines Management EPMA intranet page.
- Community Clozapine Titration Team Documents
- Inpatient Clozapine Initiation Documents
- HMP01 - HMP Liverpool & HMP Altcourse Clozapine Guidance
- Pre-Dispensed Clozapine Quarantine Reconciliation Record
- This template may be used by Clozapine Clinics / Health & Wellbeing Clinics
Valproate Decision Support Tool - Bipolar: Is valproate the right choice?
There is an expectation for all Community Teams to have their own local protocols to cover all medicines activities undertaken. The following templates have been developed to assist managers and staff:
- Protocol 01 - Accessing the medicine store, cupboard and fridge
- Protocol 02 - Using the stock medication reconciliation record (order, receipt, issue & stock check)
- Protocol 03 - Using the named patient medication reconciliation record (order, receipt, issue & stock check)
- Protocol 04 - Delivery of medication from the Trust supplying pharmacy
- Protocol 05 - Administering stock medication
- Protocol 06 - Administering named patient medication
- Protocol 07 - Counselling service users on medication issues
- Protocol 08 - Transporting medication
- Protocol 09 - Reporting medication balance discrepancies
- Protocol 10 - Monitoring medicine store and fridge temperatures
- Protocol 11 - Ordering and storing prescription stationery
- Protocol 12 - Removing or destroying PODs
- Protocol 13 - Dealing with lost medication
- Risk assessment for insulin administration by HCSWs
- To be completed by the register nurse/registered practitioner who will take responsibility for delegation of the task
- Agreement form to consent to administration of insulin
- The registered nurse/registered practitioner must obtain informed consent (see Appendix 3) to the delegation of the task from the person receiving care, or where that person does not have the capacity to give consent, the principles of the Mental Capacity Act (2005) should be followed as set out in the Consent to Treatment Policy (2015) and Mental Capacity Act (2005).
Forms can now be found on a designated Medicines Management Forms intranet page.
Training declaration forms related to Medicines Management internal training can be found on the Medicines Management Education & Training intranet page.
- Medicines Related Policy and Procedure Update September 2024
- Medicines Related Policy and Procedure Update August 2024
- Medicines Related Policy and Procedure Update June 2024
- Medicines Related Policy and Procedure Update May 2024
- Medicines Related Policy and Procedure Update March 2024
- Medicines Related Policy and Procedure Update December 2023
- Medicines Related Policy and Procedure Update July 2023
- Medicines Related Policy and Procedure Update June 2023
- Medicines Related Policy and Procedure Update May 2023
- Medicines Related Policy and Procedure Update April 2023
- Medicines Related Policy and Procedure Update March 2023 (2)
- Medicines Related Policy and Procedure Update March 2023 (1)
- Medicines Related Policy and Procedure Update February 2023 (1)
- Click here for the MMP08 Administration of Medicines visual training aid
- Medicines Related Policy and Procedure Update January 2023 (2)
- Medicines Related Policy and Procedure Update January 2023 (1)
- Medicines Related Policy and Procedure Update December 2022
- Medicines Related Policy and Procedure Update November 2022
- Click here for the MMP04 Overt and Covert Medicines visual training aid
- Medicines Related Policy and Procedure Update October 2022
- Medicines Related Policy and Procedure Update September 2022
- Click here for the MMP07 Medicines Reconciliation visual training aid
- Medicines Related Policy and Procedure Update July 2022
- Click here for the MMP19 Transcribing visual training aid
- MMP01 Controlled Drugs Summary June 2022
- Click here for the visual training aid
- Medicines Related Policy and Procedure Update June 2022
- MMP02 Unidentifiable Substances Summary June 2022
- Click here for the visual training aid
- Medicines Related Policy and Procedure Update April 2022
- Medicines Related Policy and Procedure Update February 2022