Legislative requirements for the management of medications are governed by the Drugs, Poisons and Controlled Substances Act 1981, the Drugs, Poisons and Controlled Substances Regulations 2017 and the Poisons Standard 2017 -F2017L00605. The BHS Poisons Control Plan outlines how BHS complies with this legislation, with the Director of Pharmacy responsible for compliance.

All scheduled medicines required by the patients are to be available to patients in a timely manner and in line with legislative requirements, local protocols and guidelines.

Authorised Persons: Staff with medication authorities under the Drugs and Poisons Controlled Substances Act and Regulations.

Enrolled Nurse (EN): registered with the Nursing and Midwifery Board of Australia as an Enrolled Nurse and whose registration does not preclude the handling and administration of medications.

Imprest: Medicines kept permanently on a ward (in a secured room or cupboard), that are stocked to set levels.

Medication Chart: Refers to any of the following National Standard Medication Charts: Medication Chart MR/700.2, Long Stay Medication Chart MR/715.2, Long Stay Medication Chart (Variable Dose) MR/715.1, Paediatric Medication Chart MR/700.5. It may also refer to medication specific charts such as the heparin infusion chart, clozapine chart etc.

MRN: The patients medical record number.

National Tall Man Lettering List: The ACSQHCs standardised list of medicine names that use a combination of lower and upper case letters to highlight the differences between look-alike medication names, helping to make them more easily distinguishable.

Patient: In this policy will refer to patients, clients or residents.

Pharmacy: Refers to the main Pharmacy and BRICC Pharmacy

Schedule 2 (S2): Pharmacy Medicine

Schedule 3 (S3): Pharmacist Only Medicine

Schedule 4 (S4): Prescription Only Medicine
Within this CPP, Schedule 4 medicines is a term used to describe medicines that are listed in Schedule 4 only but does not refer to any Schedule 4 medicines which are also classified as Schedule 4D medicines.

Schedule 4D (S4D): S4D medicines refers to S4 medicines that have a greater potential for addiction or abuse (e.g. benzodiazepines) and are therefore, subject to different storage and handling requirements.

Schedule 8 (S8): Controlled Drug. Substances which should be available for use but require restriction of manufacture, supply, distribution, possession and use to reduce abuse, misuse and physical or psychological dependence.

Schedule 4D (S4D) and Schedule 8 (S8): These are medicines that have a recognised therapeutic need but also a higher potential for misuse, abuse and dependence. S4D and S8 medicines are also known as Drugs of Dependence (DDs).

S19 Medications: Medications not approved by the TGA but are approved for import and supply in Australia because there is a shortage of medicine registered in Australia and the medicine is needed in the interest of public health.

Special Access Scheme (SAS) medications: Certain health practitioners may access medicines not on the TGA for a single patient. Applications should be submitted through the SAS online system.

Schedule 2, Schedule 3 and Schedule 4 medicines:

Imprest:
Wards areas or departments that have a requirement to access medicines at regular intervals generally have an imprest. The imprest is restocked by Pharmacy at pre-determined intervals depending on the stock turnover of the area and the volume of stock required. Imprest medicines are unlabelled. They are kept in a locked cupboard or drug room with the shelving labelled (National Tall Man Lettering and barcode) until they are transferred to the patient's locked bedside drawer or medication trolley by Nursing or Pharmacy staff. On discharge of the patient, these medicines are returned to the imprest by Nursing or Pharmacy staff. Expiring stock is tracked by the Pharmacy Department and expired medicines are returned to the main Pharmacy for recording and disposal.

Requisition:
The blue Pharmacy requisition book is used to order imprest stock that is running low or has run out between regular imprest refills or for wards where pharmacy does not perform routine refills. Only medicines that are on the ward/units imprest can be ordered by requisition. 

Individual patient dispensing:
Medicines required for a patient which is not kept on imprest is supplied during Pharmacy opening hours through individual patient dispensing. See Appendix Two Ordering of non imprest stock for inpatient use for the procedure.

Clinical pharmacists are the first contact point for any individual patient dispensing requests in areas with a clinical pharmacist.

If the pharmacist is not available, or a pharmacist is not rostered to the ward/unit, the main or BRICC Pharmacy as appropriate can be contacted for assistance. BRICC pharmacy should be contacted for cytotoxic or chemotherapy agent for cancer treatment.

The medicine is dispensed from the Medication Chart (or a copy) or in the BRICC Pharmacy from the ARIA system.  Pharmacist authorisation is required before processing.

This medicine is labelled with the drug details, patient name and MRN, a green 'For inpatient use' sticker (or this wording is printed on the label), but not usually directions (as they may change). Other information will be added as required for storage (e.g. refrigeration, expiry, protect from light) or safety (e.g. instructions for intravenous administration, once weekly).

This medicine is delivered to the ward or department by the Pharmacy delivery service, ward assistants, via the Lamson tube system or collected by Nursing Staff.

When the patient is discharged, these medicines are returned to the tub marked 'Pharmacy Returns' by Nursing or Pharmacy staff. The unused stock is then returned to the Pharmacy when the imprest is next checked. However, medicines that have been dispensed with full instructions on how to use the medicines (i.e. dose and frequency given on the label), and are to be continued on discharge with the same directions and are single patient use only (e.g. inhalers, creams), may be sent home with the patient - check with Pharmacy staff if unsure.
Note: Patient's Own Medicine is to be returned to the patient on discharge where appropriate. If this has been forgotten, the ward should attempt to return the medicine to the patient. If this is not possible, return to the main Pharmacy for returning to the patient or for destruction.

Out of Pharmacy hours:

A number of different options exist for sourcing medicines outside of Pharmacy opening hours. Patient's own medicines may only be used as outlined in Medication - Use of Patient's Own - CPP0095. If patient's own medicine is not suitable or is unavailable, refer to Appendix One After hours: Using the intranet to locate medicines. Any medicine removed from a ward/unit must be recorded on the After Hours Drug Redistribution Sheet located in that ward/unit's medication room.

The Patient Flow Coordinator/After Hours Coordinator must be contacted if the medicine is not available on imprest and it is to start outside of Pharmacy hours. The Patient Flow Coordinator/After Hours Coordinator will contact the On Call Pharmacist if necessary. Where a medicine cannot be sourced, this must discussed with the prescriber or responsible Medical Officer. The appropriate code should be placed on the medication chart and the reason documented in the Medical Record.

The After Hours Drug Redistribution Sheet will be collected and replaced each month by Pharmacy staff. The Pharmacy will keep records for a minimum of 3 years.

Schedule 4D and Schedule 8 medicines:

The process for ordering from the Pharmacy varies from ward to ward - contact the main or BRICC Pharmacy as appropriate for more information. A flow chart for using the card system is included in Appendix Three.

Wards are provided with red requisition books for the return of unwanted/expired stock to the Pharmacy. The procedure is outlined in Appendix Three. Stock is not to be destroyed on the ward except for part ampoules/vials/tablets/other formulations as described in Medication Storage and Security CPP0496.

Medicine is delivered to the ward as described in Medication Storage and Security CPP0496.

After hours Schedule 4D and Schedule 8 medicines can be sourced and transferred as outlined above, but have the additional requirement of the transfer of the medicine being recorded by two Nursing staff in both wards S4D and S8D registers.

The Pharmacy will keep records of S4D and S8 medicine transactions for a minimum of 3 years.

All Schedule 8 transactions (except computer data entry) are carried out in the Pharmacy by Pharmacists or a Pharmacy Intern/Student under the supervision of a Pharmacist.

SAS/S19 Products

SAS/S19 products will only be used when Australian alternatives are not available. If the medication name is not in English or special directions for use/administration are required additionally labelling will be attached by the pharmacy department prior to the stock going to the ward.