|Title:||Reporting of medicine discrepancies in public hospitals and licensed private facilities which provide services to public patients in Western Australia|
|Document ID:||Operational Directive OD 0377/12|
|Date of issue:||Tuesday, 12 June 2012|
|Description:||This Operational Directive outlines the requirements for investigating and reporting discrepancies in stock levels of medicines, including restricted Schedule 4 and Schedule 8 medicines, in public hospitals and licensed private facilities providing services for public patients in WA.|
|Legal requirements:||Poisons Regulations 1965
|Applicable to:||Staff who handle medicines and work in public hospitals or licensed private facilities which provide services to public patients.|
|Framework:||Public Health Policy Framework|
|Period of effect:||from 1 July 2012 to 30 June 2022|
|Review date:||1 July 2017|
|Authorised by:||Kim Snowball, Director General, Department of Health WA, 26-May-2012|
|Print version:||View print version|
Reporting of medicine discrepancies in public hospitals and licensed private facilities which provide services to public patients in Western Australia
All public hospitals (including public hospitals providing services for private patients) and licensed private facilities which provide services to public patients in Western Australia (WA) must have controls in place to reduce the risk of medicine loss.
Schedule 8 and restricted Schedule 4 medicines have important therapeutic uses but may be targeted for diversion or abuse. Theft, unauthorised use or unaccounted loss of any medicine can be due to inadequate security, storage, record keeping or general control of these medicines.
The Poisons Regulations 1965 require that:
Operational Directive 0215/09, Storage and Recording of Restricted Schedule 4 Medicines, requires that:
Operational Directive 0036/07, WA Health Misconduct: Reporting requires that:
This Operational Directive outlines the requirements for investigating and reporting discrepancies in stock levels of restricted Schedule 4 and Schedule 8 medicines in public hospitals and licensed private facilities providing services for public patients in WA.
3.1. Hospitals and private facilities
3.1.1. All hospitals and private facilities providing services to public patients are required to:
3.1.2. The Executive Director of each site must designate a Medication Incident Coordinator (MIC) for the purpose of this Operational Directive.
3.1.3. The MIC:
3.1.4. One MIC may be nominated for multiple physical locations under the oversight of one central site (E.g. a WA Country Health Service region or tertiary hospital plus annexes) or one site may nominate multiple MICs who each have jurisdiction over specific physical locations at the site (E.g. a different MIC for Emergency Departments and nominated wards).
3.1.5. All sites must advise the CGD of the position/s nominated as MIC (E.g. Chief Pharmacist, Director of Nursing) and provide contact details for the current occupant/s of the position/s.
3.2. Medication Incident Coordinator
It is the responsibility of the MIC to:
3.2.1. Oversee and manage the process for investigating and reporting medicine discrepancies.
3.2.2. Nominate an Incident Reviewer for each incident of medicine loss.
3.2.3. Retain all records of reports for the site.
3.2.4. Conduct system/practice reviews and trend analysis of discrepancy reports where applicable.
3.2.5. Progress the implementation of any recommendations or identified system improvements required.
3.2.6. Be the contact person for Departmental investigation and follow-up.
3.3. Incident Reviewer
3.3.1. It is the responsibility of the Incident Reviewer to conduct a review of each discrepancy as assigned by the MIC.
3.3.2. The Incident Reviewer must be authorised to review patient charts and correct or annotate the Register if required.
3.3.3. The MIC may be nominated as Incident Reviewer; however, independence is strongly encouraged.
4.1. Where a discrepancy is identified, the person who identified the discrepancy (the Notifier) must, as soon as possible and within 24 hours:
4.1.1. Notify a Senior Pharmacist/Ward Pharmacist, Senior Registered Nurse/Midwife and security (if applicable).
4.1.2. Conduct the follow-up procedure as per Section 1 of the Medicine Discrepancy/Loss (MD/L) report form.
4.1.3. Correct the Register balance to reflect stock on hand.
4.1.4. Where the initial follow-up confirms the medicine loss (i.e. does not locate the medicine):
4.2. On receipt of Section 1 of the MD/L Report the MIC must, as soon as possible:
4.2.1. Nominate an Incident Reviewer for each incident of confirmed medicine loss. The Notifier may be nominated as Incident Reviewer; however, independence is strongly encouraged.
4.2.2. Forward the MD/L report form to the Incident Reviewer.
4.2.3. Report suspected misconduct. The MIC is to contact site Human Resources or the CGD to obtain assistance with reporting.
4.3. On receipt of the MD/L Report the Incident Reviewer must, as soon as possible and within 72 hours of the discrepancy being identified:
4.3.1. Confirm initial findings.
4.3.2. Conduct an incident review as per Section 2 of the MD/L Report form.
4.3.3. Correct the Register balance where medicines are located or it is determined that no loss occurred (e.g. where a dose has been administered but not recorded).
4.3.4. Report losses or theft of poisons to WA Police.
4.3.5. Notify the Hospital Director of Pharmacy, Unit Director and security (if applicable) of the findings.
4.3.6. Submit the MD/L report form to the MIC.
4.4. On receipt of Section 2 of the MD/L Report the MIC must:
4.4.1. Conduct practice/system reviews and trend analyses for explained practice/systems related losses and for instances where it is identified no loss occurred or medicines were located. Practice reviews and trend analysis may identify process improvements or performance management issues. These matters should be raised with the relevant Area Manager or line manager as required.
4.4.2. Progress the implementation of any recommendations or identified systems improvements.
4.4.3. Outline further investigations required for unexplained losses and nominate a contact person for these investigations.
4.4.4. Report suspected misconduct.
4.4.5. Complete Section 2 of the MD/L Report and forward to the CGD, DOH within 72 hours of the discrepancy being identified.
4.5. If additional relevant matters come to light, after reports are submitted to the CGD, additional advice should be provided on a timely basis.
This circular last updated: Monday, 4 May 2015 at 3:46pm