NHS Borders clinical guidelines
When a discrepancy is detected between the ward CD register/Omnicell balance and the physical balance in stock then the nursing staff that discovers the discrepancy must ensure that the nurse in charge is made aware immediately. For wards with omnicell cabinets a discrepancy slip will automatically be generated if the amount entered confirming the physical balance in stock does not match the online register balance. The discrepancy slip should be given to the nurse in charge to follow up.
The following steps should be taken by the investigating nurse (nurse in charge). They should complete a CD balance discrepancy report form APPENDIX 1 to show the steps that they have taken to attempt to resolve the discrepancy.
- Check arithmetic since last correct balance and confirm when stock check/correct balance was recorded to allow a time frame to be defined.
- Check all controlled drug stocks with a second person
- Check other register sections of same drug class for erroneous entries
- Sense-check register (correct pack sizes, patterns of entry for potential missing entries, and unusual quantities)
- Check diary and contact all members of staff who have worked in the clinical area during the relevant period to verify any supplies made that have not been entered
- Check all requisitions received have been entered into the correct page of the register. For wards with Omnicell the online register can be accessed by those with authority using the following link. OMNICELL controlled drugs register access
- Check all CDs administered have been entered into the CD record book/Omnicell (Medicine charts of patients who have been prescribed the drug may have to be compared to entries on Omnicell or in the CD ward register)
- Check items have not been accidentally put into the wrong place in the cabinet.
If the error or omission is traced, the registered nurse, midwife or ODP in charge should make an entry in the CD Record Book clearly stating the reason for the entry and the corrected balance. This entry must be witnessed by a second nurse, midwife, ODP, pharmacist, pharmacy technician or doctor. Both persons must sign the CD Record Book.
Please see example below:
In wards with Omnicell cabinets, see guide:- Guide for Dealing with CD Discrepancies – at APPENDIX 2
If no errors or omissions are detected then an adverse event report (InPhase) must be completed, Out of hours the nurse in charge of the hospital must be informed. Pharmacy or the ward pharmacist must be contacted and the time and date must be noted in register. If the discrepancy cannot be resolved it must be reported to the Controlled drug team and the police as soon as possible, within 48 hours.
For unresolved discrepancies recorded in CD registers a note should be made next to the entry ex:
‘discrepancy reported to CD team (add date) InPhase report completed (add date) ref number: (add InPhase reference number). ........ (signature)’.
This will make staff aware that the discrepancy is under investigation.
The completed CD balance discrepancy form should be emailed to the CD team. borderscdteam@borders.scot.nhs.uk