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Worcestershire Key Documents
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Medicines Key Documents

 New Key Documents Application

All Trust key documents have now been moved to a new application.

Please use this app to ensure that you are using the most up to date version of the document.

Click this link for Key Documents

Adult Antimicrobial Guide

Animal derived medical products - trust guideline for patients who do not wish to receive medicines containing animal extracts

Review date - 8th July 2023 

This is the most current document and should be used until a revised version is in place

Antimicrobial Stewardship Policy

Review Date - 25th June 2024

This is the most current document and should be used until a revised version is in place

Guideline for the Use of Argatroban in Critical Care

Review Date - 15th January 2023

This is the most current document and should be used until a revised version is in place

Guidelines for medicines management following bariatric surgery

Review date - 14th July 2024

This is the most current document and should be used until a revised version is in place

Guideline for the Use of Clonidine for Sedation in Adult Intensive Care

Review Date - 4th May 2023

This is the most current document and should be used until a revised version is in place

Guidance for handling the spillage of Systemic Anti-Cancer Therapy (SACT) drugs

Review date - 28th September 2022

This is the most current document and should be used until a revised version is in place

Guideline for the Use of Dexmedetomidine in Critical Care 

Review Date - 15th January 2023

This is the most current document and should be used until a revised version is in place

Guidelines on the use of 'extended interval' aminoglycoside (gentamicin and tobramycin) therapy

Review date - 30th June 2022

This is the most current document and should be used until a revised version is in place

Treatment of Hypomagnesaemia

Review date - 14th July 2024

This is the most current document and should be used until a revised version is in place

Acute treatment of Hypophosphataemia guidelines

Review date - 19th May 2023 

This is the most current document and should be used until a revised version is in place

Management of Hypocalcaemia in adult inpatients

Review date - 10th February 2023

This is the most current document and should be used until a revised version is in place

Guideline for the Management of Adult Patients with Malignant Hypercalcaemia

Review Date - 11th May 2025

This is the most current document and should be used until a revised version is in place

Guideline for the management of Hypokalaemia in Adults

Review date- 15th January 2023

This is the most current document and should be used until a revised version is in place

Guideline on the Management of High Output Stoma 

Review Date - 8th July 2023

This is the most current document and should be used until a revised version is in place

Policy and procedure for the administration of injectable medicines

Review date - 8th December 2024

This is the most current document and should be used until a revised version is in place

Worcestershire Acute Hospitals Non-Medical Prescribing Policy

Review date - 4th November 2022

This is the most current document and should be used until a revised version is in place

Medicines policy

Review date - 8th July 2023

This is the most current document and should be used until a revised version is in place

Nil by mouth and peri-operative medicines use guideline

Review Date - 12th August 2024

This is the most current document and should be used until a revised version is in place

Guideline for the management of adult opiate dependent patients in the acute hospital setting

Review date - 1st September 2023

This is the most current document and should be used until a revised version is in place

Parenteral nutrition guidelines

Review date - 14th July 2024

This is the most current document and should be used until a revised version is in place

Guidelines on the use of St Mark's solution in patients with a short bowel

Review date - 19th January 2024

This is the most current document and should be used until a revised version is in place

Guidelines for the use of Intravesical Gentamicin to treat Recurrent UTIs

Review date - 12th May 2024

This is the most current document and should be used until a revised version is in place 

Aqueous Iodine Oral Solution BP - Patient Information

Review date - 1st June 2022

This is the most current document and should be used until a revised version is in place 

Tranexamic Acid Mouthwash 5% - Patient Information

Review date - 1st June 2022

This is the most current document and should be used until a revised version is in place 

MedPol SOP1 Non-Pharmacy dispensing 

Review Date – 12th August 2023

This is the most current document and should be used until a revised version is in place

MedPol SOP2
Now included in MedPolSOP1

MedPol SOP3 Handing a Pharmacy dispensed medicine to a patient to take home

Review Date  - July 2023

This is the most current document and should be used until a revised version is in place

MedPol SOP5 Unlicensed Medicines

Review Date – 30th September 2022

This is the most current document and should be used until a revised version is in place

MedPol SOP6 Using Medicines outside their license i.e. "Off-Label"

Review Date – 30th September 2022   

This is the most current document and should be used until a revised version is in place

MedPol SOP7 Controlled Drugs

See link to COVID-19 amendment to sections 7 (ordering), 11 (receiving), 18 (CD keys), and 30 (audits and statutory checks)

Review Date – 8th December 2024

This is the most current document and should be used until a revised version is in place

MedPolSOP7R (Radiology) - withdrawn 1/4/2020 and incorporated into MedPolSOP7 

MedPol SOP8 Controlled Drug Access Lists

Review Date – 30th November 2022

This is the most current document and should be used until a revised version is in place

MedPol SOP9  Supply, Administration, Storage and Transfer/TTOs of Insulin

Review Date – 30th September 2022 

This is the most current document and should be used until a revised version is in place

MedPol SOP10 Prescribing / Dispensing / Supplying / Applying Paraffin Based Skin Products and non-paraffin based emollients - reducing the associated Fire Hazard

Review Date – 8th December 2024

This is the most current document and should be used until a revised version is in place

MedPol SOP11 Administration of Oral and Enteral Liquid Medicines

Review Date – 2nd December 2022  

This is the most current document and should be used until a revised version is in place

MedPol SOP13 Patients Self Administering Medicines as In-patients (to be reviewed and updated when proposal received by Medicines Safety Committee) 

MedPol SOP14 Reducing Risk of Overdose With Midazolam Injections in Adults

Review Date – 30th September 2022    

This is the most current document and should be used until a revised version is in place

MedPol SOP15 Reporting Adverse Reactions

Review Date – July 2023

This is the most current document and should be used until a revised version is in place

MedPol SOP16R Bowel Prep Procedure in Radiology Departments

Review Date – 18th April 2024

This is the most current document and should be used until a revised version is in place

MedPol SOP17 Controlled Drugs Discrepancy Procedure

Review Date – 8th December 2024

This is the most current document and should be used until a revised version is in place

MedPol SOP18 Controlled Drug missing keys procedure

Review Date  - 14th April 2024 

This is the most current document and should be used until a revised version is in place

MedPol SOP19 Purchasing for safety

Review Date - 7th October 2022

This is the most current document and should be used until a revised version is in place

MedPol SOP20 Standard Operating Procedure (SOP) for Adult Ward Medicines Administration

Review Date -  9th September 2023

This is the most current document and should be used until a revised version is in place

MedPol SOP21 Standard Operating Procedure (SOP) for Paediatric Ward Medicines Administration

Review Date – 12th May 2024  

This is the most current document and should be used until a revised version is in place

MedPol SOP22 Standard Operating Procedure (SOP) for Neonates Ward Medicines Administration

Review Date – 12th May 2024 

This is the most current document and should be used until a revised version is in place

MedPol SOP23 Standard Operating Procedure (SOP) for Supply, Storage, Prescribing and Handling of Strong Potassium Infusions and Concentrate

Review Date – 31st March 2024  

This is the most current document and should be used until a revised version is in place

MedPol SOP25 Standard Operating Procedure (SOP) for Managing Staff Involved In Medication Errors
Replaced by Just Culture Guide

MedPolSOP27 Outpatient Prescribing (including FP10s)

Review Date – 31st December 2024  

This is the most current document and should be used until a revised version is in place

MedPolSOP28 Safe management of ONCE WEEKLY Methotrexate for non-malignancy on acute admission

Review Date – 12th May 2024

This is the most current document and should be used until a revised version is in place

MedPolSOP29  Monitoring and management of medicine fridge and room temperatures

Review Date – 14th April 2024

This is the most current document and should be used until a revised version is in place

MedPolSOP31 Patient Group Directions Procedure

Review Date – 14th July 2024

This is the most current document and should be used until a revised version is in place   

MedPolSOP32 Medicines Key Security - use of key safes

Review Date – 14th April 2024

This is the most current document and should be used until a revised version is in place

MedPolSOP33 Safe and Secure Handling of FP10

Review Date – 31st December 2024  

This is the most current document and should be used until a revised version is in place

Management of Suspected and Confirmed Vaccine Induced Thrombocytopenia and Thrombosis (VITT) in adults

Review date - 11th June 2024

This is the most current document and should be used until a revised version is in place 

Coagulopathy in COVID-19: Recommendations for Laboratory Testing and Thromboprophylaxis

Review date - 12th November 2022

This is the most current document and should be used until a revised version is in place 

Remdesivir Treatment Protocol

Review date - 1st July 2024

This is the most current document and should be used until a revised version is in place 

Interim Clinical Commissioning Policy: Casirivimab and Imdevimab for patients hospitalised due to COVID-19

Review date - 8th October 2024

This is the most current document and should be used until a revised version is in place

COVID-19 Vaccine Handling and Management Policy

Review date - 13th April 2023

This is the most current document and should be used until a revised version is in place

Page last updated: 05 September 2022