Aim Following on from identification by the medication safety collaborative that wards had a build-up of Controlled Drug (CD) medication not given on discharge this audit aims to establish why CD medications that had been dispensed by pharmacy as part of a patients take home medication (TTO) had not been issued to patients at the point of discharge.

Method Pharmacy completed an audit of all ward areas that routinely discharge patients’ home (therefore excluding Intensive Care and High Dependency Unit) on one set day to establish the number of uncollected CD medications. Data collection included the total number of CD items dispensed by pharmacy but not issued upon discharge to the patient, the details of what these CD items were and the ward staff comments as to why the item had not be given upon discharge.

As these items belonged to patients no longer being treated within the trust they were appropriately returned to pharmacy, to ensure the correct denaturing of the CD was undertaken prior to disposal. It was at this stage that the amounts of CD medication wasted as dispensed products unable to be used was also recorded.

Results The data collected established that all 7 inpatient ward areas had at least 1 CD medication that had been dispensed as part of the patients TTO but not issued on discharge. The were a total of 28 CD medications stored in trust CD cabinets not given on discharge of which 39% involved a legally classified schedule 2 or 3 CD. 54% of the unissued medications involved Morphine oral solution 2 mg/ml amounting to a total waste of 653 ml.

In 71% of the situations staff commented the CD medication had not been issued upon discharge as it was unwanted by the patient or parents of the child or staff had concluded the medication to no longer be clinically necessary for the patient as the TTO had been completed in advance of the discharge date and the clinical picture had changed. or they did not retrieve it from the cabinet at the point of discharge.

Conclusion This audit suggests there is a flaw in the discharge of patients who are prescribed CD items. It has flagged the need for an immediate review of the discharge process to ensure that discharge paperwork reflects that certain items have not been provided upon discharge. We need to incorporate a system that closes the loop in relation to CD governance whereby we can be assured that the CD medication dispensed by pharmacy is issued to the patient.

Pharmacy should embed the return of unnecessary CD medication as part of routine practice and challenge patterns of not issuing dispensed medication. As a result of the high amount of CD waste we are also considering the practicality of ward level destructions to reduce any potential safety incidents, ie; some of the unissued CD medication found in the CD cabinets was found to be out of date.