|Title:||Reporting of Schedule 8 medicine stock discrepancies in WA public hospitals|
|Document ID:||Operational Directive OD 0140/08|
|Date of issue:||Tuesday, 29 July 2008|
|Status:||NO LONGER APPLICABLE|
|Description:||Requirement for notification of stock discrepancies of Schedule 8 medicines in public hospitals to Corporate Governance Directorate.|
|Applicable to:||All hopital personnel.|
|Category:||Accountability & Audit|
|Period of effect:||from 9 July 2008 to 9 July 2013|
|Review date:||1 May 2013|
|Authorised by:||Dr Robyn Lawrence, A/DIRECTOR GENERAL, WA HEALTH, 18-Jul-2008|
|Print version:||View print version|
|To be read in conjunction with:||
Reporting of Schedule 8 medicine stock discrepancies in WA public hospitals
Schedule 8 medicines have important therapeutic uses but some of these medicines may be targeted by persons with the intention of inappropriate use, including diversion or abuse.
This Operational Directive outlines the reporting requirements for all identified discrepancies in the stock levels of Schedule 8 medicines in public hospitals and licensed private facilities providing services for public patients in Western Australia (WA).
The Poisons Act 1964, Poisons Regulations 1965 and Misuse of Drugs Act 1981 set out the restrictions on the possession, storage and access to Schedule 4 and Schedule 8 medicines in WA. A person who has been issued with a Poisons Licence or Permit under the Act (the “authorised person”) is responsible for the secure storage of such medicines. In public hospitals, the authorised person will generally be a pharmacist.
The Regulations also specify the record keeping requirements associated with access to these medicines. For Schedule 8 medicines, Regulation 44(4) requires that a Register be maintained so that the amount of each Schedule 8 medicine procured, used, supplied or stored is apparent. If an inventory of stock does not agree with the balance in the Register, Regulation 45(2) requires that the authorised person immediately notify the Chief Executive Officer of Health in writing. The Pharmaceutical Services Branch has the regulatory responsibility for ensuring compliance with the poisons legislation.
Regulation 32 requires that a person who loses a poison, which includes Schedule 4 and Schedule 8 medicines, or from whom any poison is stolen, shall immediately notify the Police of such loss or theft.
All discrepancies in the stock of Schedule 8 medicines that occur in public hospitals and other facilities, which provide services to public patients in WA, are required to be investigated and reported.
Prior to a reportable event being identified, a staff member may have concerns about the possible loss, theft or diversion of a Schedule 8 medicine within a hospital facility. This may include but is not limited to:
Public hospitals and other facilities which provide services for public patients in WA should establish procedures for investigating and reporting such concerns. The early involvement of the “authorised person” for the facility is recommended. At this stage, contact may also be made with the Corporate Governance Directorate for assistance.
PROCESS FOR REPORTING
The Pharmaceutical Services Branch has the responsibility of ensuring compliance with the Poisons Act 1964 and Poisons Regulation 1965. To avoid the need to report to multiple areas of the Department, all identified discrepancies in the stock of Schedule 8 medicines must be reported to the Corporate Governance Directorate within 24 hours of the discrepancy being identified. The person identifying the discrepancy should make the report and include the names of any other staff members who have been notified of the discrepancy and the action that has or will be taken within the facility to progress investigation of the discrepancy. Reports should be made via the Notification of Schedule 8 Stock Discrepancy form (see attachment) and send to the Corporate Governance Directorate by fax, on (08) 9222 2398, or by email to firstname.lastname@example.org.
The requirement to report the stock discrepancy does not alleviate the responsibility of the facility to conduct a thorough investigation to attempt to locate the cause of the discrepancy and the stock itself. The results of any preliminary investigation should be annotated on the form prior to it being forwarded to the Corporate Governance Directorate.
If the stock is located and/or further developments arise from any investigation, a supplementary report should be provided to Corporate Governance.
An Operational Directive on the ‘Reporting of select Schedule 4 medicine stock discrepancies in WA public hospitals’ is being developed and will be issued shortly.
Dr Robyn Lawrence
This circular last updated: Tuesday, 29 July 2008 at 12:19pm