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Online prescribers and home delivery cited in CD mismanagement

CQC report highlights CD governance gaps

July 8th 2022

Tagged: Clinical guidance news Dispensary guidance news CQC

By Ailsa Colquhoun

Incidents associated with online prescribing and home delivery services involving controlled drugs are among the concerns noted by the CQC in its annual report on The safer management of controlled drugs. 

The report notes a number of situations that could or do result in mismanagement of CDs. These include:  

  • people registering as temporary residents with GPs to obtain controlled drugs inappropriately and/or obtaining additional supplies of controlled drugs from multiple sources 
  • unauthorised collections of CDs on behalf of a patient  
  • inappropriate prescribing by both medical and non-medical prescribers either for themselves, or someone close to them 
  • keeping temporary staff up to date with changes to local CD policies and procedures  
  • incomplete CD balance checks 
  • storing CD and paper prescriptions safely and securely, and the associated risks of potential diversion. 

Among the improvements to CD governance, the CQC calls for CD balance checks to be fit for purpose, according to the volume of CDs stored and dispensed. There should also be better review of CD incidents – both within organisations and to relevant external organisations (such as NHS England and CQC) – and better controls on repeat prescriptions for CDs.  

GPs are urged to improve monitoring of patients taking dependence-forming controlled drugs, or where a combination of CDs are prescribed that are known to increase the risk of over-sedation or other side effects.

The report also notes weaknesses in electronic prescribing systems affecting the management of CDs.