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If a procedure cannot be found for a former Division, check that this has not been superseded by a Trust wide policy/procedure.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 2025

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 - update expected May 2025

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 Jan 2025

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 2025

MMP28 Management of Thickening Agents in SALT Teams for Assessment

MMP29 Management of Anticoagulation Therapy

MMP30 Medical Gas Cylinders Procedure (associated with SD59) - expected 2025

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

MMP53 Medicines Management in the ICRAS Team

MMP54 Medicines Management in the ADHD Services

Trust Wide Policies

SD12 Safe and Secure Medicines

MCT08 Controlled Drugs

MM05 Non Medical Prescribing

SA50 Patient Group Directions

SD59 Safe Management of Medical Gas Cylinders

The procedures below are service specific and are applicable to the Medicines Management Team only:

The procedures below are applicable to the Medicines Management Department only and can be found on the S: drive > 'Pharmacy' Folder:

The procedures below are applicable to the Medicines Management Clinical Trials Team only: 

The procedures below are applicable to the Medicines Information & Formulary Team only: 

EPMA User Guides / Procedures can be found here on the Medicines Management EPMA intranet page.

Valproate Decision Support Tool - Bipolar: Is valproate the right choice? 

  • 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.