Article Text

Download PDFPDF

P25 Improving stock accountability of liquid controlled drugs using rulers in a children’s hospital
  1. Ka Yu Yung
  1. Great Ormond Street Hospital


Context The Controlled Drugs (CD) (Supervision of Management and Use) Regulations 2013 lays out the legislation for monitoring of the management and use of CDs.1 Inaccurate counting and poor record keeping of CDs can reduce staff time for patient facing activities.2 It is a national recommendation that visual inspections of stock balance should happen in various time points: periodic volume checks and checks to confirm the balance on completion of a bottle.3 Due to the patient population, a large proportion of the CDs stocked in the Trust are liquid preparations designed for multiple small volume administration. CD discrepancies contribute to over 100 Datix incident reports annually. This is largely due to volume lost during manual manipulation of bottle for dosing and weekly physical measurements undertaken by staff as per the Trust policy. It is estimated that approximately one hour of nursing time per ward/Theatre per week were taken away from clinical care for CD checks. It also introduces contamination risk due to decanting, as well as generating plastic waste associated with volume checking. To mitigate the risk, the Trust’s Medicines Safety Committee (MSC) benchmarked liquid preparations volume checks against other paediatric centres. It was found that most did not undertake routine or physical measurements. Following a Care Quality Commission’s CD National Group recommendation to consider using a calibrated bottle to aid visual inspection and accurate management3, liquid CD rulers with volume increments were explored. CD rulers allow for a volume measurement to be approximated without the need of decanting the bottle. Following MSC’s approval, the implementation of the liquid CD rulers was introduced. Ward stock lists were reviewed, and the manufacturers and brands of each liquid CD preparation was compiled into a database. Training sessions (both virtual and face-to-face) for pharmacy and nursing staff were delivered and facilitated over a period of three months, prior to implementation. The Trust CD policy was updated, and a local guidance developed, with all eventualities covered. This change in practice was communicated via email, nurse practice educators’ network, and the Trust’s medicine safety newsletter. The guidance was updated and uploaded onto the Pharmacy intranet webpage and put up in the clinical areas as a visual aid.

Lessons Learned The successful introduction of CD rulers have been well received across the Trust. The implementation required extensive support from the Trust’s educational and pharmacy team. Feedback sessions were carried out post implementation and suggestions were used to update the guideline. Although there are financial implications, there has been a reduction in the number of CD discrepancies-related incidents. They have simplified and sped up CD checks and prevent the risks of spillage, contamination, and wastages. However, they cannot be used for opaque bottles and are tailored specifically to that drug, strength, manufacturer, and pack size, giving less flexibility in response to drug contract changes/shortages. A 6-month surveillance will be conducted to fully assess and review this change in practice.


  1. The Controlled Drugs (Supervision of Management and Use) Regulations 2013. No. 373. Part 2. Regulation 12. Available at The Controlled Drugs (Supervision of Management and Use) Regulations 2013 ( [Accessed 10 June 2022].

  2. Care Quality Commission’s (CQC’s) Controlled Drugs National Group. Sub-Group Newsletter – April 2021. Issue number 11. Available at [Accessed 05 August 2021].

  3. National Institute for Health and Care Excellence (NICE). Controlled drugs: safe use and management (NG46). April 2016.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.